CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND OF THE STUDY
Cholera is an infection of the small intestine that is caused by the bacterium Vibrio cholera 01 and 0139[1].

The main symptoms are profuse watery diarrhea and vomiting.

Transmission is primarily through consuming contaminated drinking water or food.

The severity of the diarrhea and vomiting can lead to rapid dehydration and electrolyte imbalance. Every year there is an estimated 3-5 million cholera cases and 100,000-120,000 deaths due cholera.

The short incubation period of two to five days, enhance the potentially explosive pattern of out breaks [2]. Cholera transmission is closely linked to inadequate environmental management.

Typical at-risk areas include peril-urban slums, where basic infrastructure is not available, as well as camps for internally displaced people or refugees, where minimum requirements of clean water and sanitation are not met.

The consequences of a disaster – such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission should the bacteria be present or introduced.

Epidemics have never arisen from dead bodies.

Cholera remains a global threat to public health and a key indicator of lack of social development.

Recently, the reemergence of cholera has been noted in parallel with the ever-increasing size of vulnerable populations living in unsanitary conditions [3].
Two serogroups of v. cholera – 01 and 0139 – causes out breaks [4]. V. cholera 01 causes the majority of outbreak, while 0139 -first identified in Bangladesh in 1992 –is confined to South-East Asia. Non-01 and non-0139 v. cholera can cause mild diarrhea but dot not generate epidemics.

The bacteria are transmitted via contaminated drinking water or food.

Pathogenic v. cholera can survive refrigeration and freezing in food supplies [5]. The dosage of bacteria required to cause an infection in healthily volunteers via oral administration of living vibrio’s is greater than 1000 organisms [6].

After consuming an antacid, however, cholera development in most volunteers after consumption of only 100 cholera vibrio’s experiments also show that vibrio’s consumed with food are more likely to cause infection than those from water alone [7].

Cases tend to be clustered by location as well as season, with most infections occurring in children ages 1-5 years [4].
Cholera is severe water-born infectious disease caused by the bacterium vibrio cholera.

In 2005, 131,943 cases including 2,272 deaths have notified from 52 countries.

The year was marked by a particular significant series of outbreaks in West Africa, which affected 14 countries and accounted for 58% of all cholera cases world-wide [8]. In the same year Nigeria had 4,477 cases and 174 deaths.

There was reported case of cholera in 2008 in Nigeria in which 429 deaths out of 6,330 cases. More so, 2,304 cases in Niger State in which 114 were reported death in 2008 [4].

Recent years have seen a strong trend of cholera outbreak in developing countries, including among others, those in India (1), Iraq (2008), Congo (2008), Zimbabwe (2008-2009), Haiti (2010), and Kenya (2010), Koko in Edo State (1989).

In Nigeria, according to UN figure, 1,555 people have died since January and 38,173 cases have been reported.

The figure is more than four times the death toll the government reported in August [3].
Cholera is a disease characterized by profuse diarrhea accompanied with a severe dehydration and loss of electrolyte [12], caused by toxigenic Vibrio cholera, a serologically diverse, environmental, and gram-negative rod bacterium [9]. In the absence of appropriate treatment, there is a high mortality rate.

Cholera is a major public health concern because of its high transmissibility, death-to-case ratio and ability to occur in epidemic and pandemic forms [7].

Cholera is responsible for an estimated death of 120,000 globally every year [8], and still continues to be a scourge worldwide covering all continents. In developing countries with endemic areas, cholera is still very significant with incidence of more than five million cases per year [8].

The explosive epidemic nature and the severity of the disease and the potential threat to food and water supplies have prompted the listing of V. cholerae as an organism of biological defense research [11].

In an epidemic, the great majority of cases can be recognized by clinical diagnosis easily and a bacteriological diagnosis is often not required.
Cholera is endemic in Nigeria [8] and epidemiological features [4] have been reported from various parts of the country with investigations on possible sources of outbreaks.

Outbreaks of cholera had been reported from various States in Nigeria such as Ogun, Edo, Pleated State etc., of Nigeria.

Investigations on outbreak of cholera in Nigeria have focused on the epidemiological features, the probable source of contamination and the risk factors without spatial linkage of health data.

However, advances in Geographical Information Systems (GIS) technology provides this opportunity and has become an indispensable tool for processing, analyzing and visualizing spatial data within the domains of environmental health, disease ecology and public health [13].
This study will seek to assess the level of knowledge, attitude and practice towards cholera outbreak in Ilorin metropolis, Kwara state State.

1.2 STATEMENT OF THE PROBLEM
The threat of cholera rampaging through Nigeria has long been of concern to many.

The crowded settings coupled with minimal water, sanitation, hygiene and health services, present a fearsome breeding ground for cholera to quickly escalate beyond control.

In an attempt to avoid this worse-case scenario, a massive response needs to be mounted by the Government to enlighten the general public about the causes of this deadly disease and also ways to avoid the outbreak.

Hygiene promoters should be employed to work every day, sharing information on how to avoid contracting the illness and the signs and symptoms of the disease [8].
In Nigeria, 708 suspected cases of Cholera with 4 laboratory confirmed and 18 deaths (CFR, 2.54%) were reported from ten LGAs (six States; Bauchi – 3, Borno – 593, Kaduna – 28 Kano – 4 and Oyo – 8) in week 36 compared with 14 suspected cases and one death (CFR, 7.14%) reported from Oshodi/Isolo LGA in Lagos State during the same period in 2016.

Between weeks 1 and 36 (2017), 2330 suspected Cholera cases with 40 laboratory confirmed and 51 deaths (CFR, 2.19%) from 55 LGAs (17 States) were reported compared with 417 suspected cases and 14 deaths (CFR, 3.36%) from 35 LGAs (11 States) during the same period in 2016 (Figure 7).

Between weeks 1 and 52 (2016), 768 suspected Cholera cases with 14 laboratory confirmed cases and 32 deaths (CFR, 4.17%) from 57 LGAs (14 States) were reported compared with 5,301 cases with 29 laboratory confirmed cases and 186 deaths (CFR, 3.51%) from 101 LGAs (18 States and FCT) during the same period in 2015 (Figure 8).

Cholera preparedness workshop held from 31st May – 1st June, 2017 in Abuja to develop Cholera preparedness plan as the season set in.

NCDC/partners provided onsite support in Kwara, Zamfara and Kebbi States. NCDC/partners are providing onsite support in Borno State.

Cholera Preparedness Checklist sent to all States to assess their level of preparedness with recommendations for prevention of and response to an outbreak.

RDT procured by NCDC and WHO currently being prepositioned in affected States.

States are enjoined to intensify surveillance, implement WASH activities and ensure early reporting [1].
The 2010 outbreak of cholera and gastroenteritis and the attendant deaths in some regions in Nigeria brought to the forefront the vulnerability of poor communities and most especially children to the infection. The outbreak was attributed to rain which washed sewage into open wells and ponds, where people obtain water for drinking and household needs.

The regions ravaged by the scourge include Jigawa, Bauchi, Gombe, Yobe, Borno, Adamawa, Taraba, FCT, Cross River, Kaduna, Osun and Rivers.

Figure 1 depicts major outbreak locations.

Even though the epidemic was recorded in these areas, epidemiological evidence indicated that the entire country was at risk, with the postulation that the outbreak was due to hyper-virulent strains of the organism [5

Cholera prevalence by state

Figure 1: Map of Nigeria showing main regions affected by 2010 cholera outbreak.
Source: NCDC 2015

1.3 JUSTIFICATION FOR THE STUDY
In August 2010: Cholera in Nigeria reached epidemic proportions after widespread confirmation of the disease outbreaks in 12 of its 36 states. 6400 cases were reported with 352 reported deaths.

The health ministry blamed the outbreak on heavy seasonal rainfall and poor sanitation.

On 7 June 2017, World Health Organization (WHO) was notified of a cholera outbreak in Kwara State, Nigeria, where the event currently remains localized [4].

The first cases of acute watery diarrhea were reported during the last week of April 2017 and a sharp increase in the number of cases and deaths has been observed since 1 May 2017.

However, the number of new cases reported has shown a decline over the last four reporting weeks. As of 30 June 2017, a total of 1558 suspected cases of cholera have been reported including 11 deaths (case fatality rate: 0.7%).

Thirteen of these cases were confirmed by culture in laboratory. 50% of the suspected cases reported are male and 49% are female (information for gender is missing for 1% of the suspected cases).

The disease is affecting all age groups.

Between 1 May and 30 June 2017, suspected cholera cases in Kwara State were reported from five local government areas; Asa (18), Ilorin East (450), Ilorin South (215), Ilorin West (780), and Moro (50) (information for local government areas is missing for 45 of the suspected cases).

Poor sanitation conditions observed in the affected communities is one of the predisposing factors for this cholera outbreak. An important risk factor is the lack of access to clean drinking water and poor hygiene conditions [8].
1.4 RESEARCH QUESTION
The following research questions will be asked and answered in the study:
1. Does poor environmental sanitation lead to cholera outbreak?
2. Does washing of hands before eating help to prevent cholera infection?
3. Can drinking and bathing with contaminated water lead to cholera outbreak?
4. Does poorly kept toilet cause cholera outbreak?
5. Is cholera outbreak rampant during the rainy season?
6. Does the use of pipe borne water for drinking and cooking help reduce cholera outbreak?
7. Does boiling of water reduce the risk of cholera infection?

1.5 OBJECTIVE OF THE STUDY
1.5.1 GENERAL OBJECTIVE:
To determine the level of knowledge, attitude and practices of people of Ilorin metropolis towards cholera transmission and prevention
1.5.2 SPECIFIC OBJECTIVES OF THE STUDY:
1. To identify the causes and effects of cholera in Ilorin.
2. To ascertain if cholera outbreak is usually rampant during the rainy season in Ilorin.
3. To identify the problems associated with the prevention of cholera in Ilorin.
4. To determine the ways of preventing cholera outbreak in Ilorin.
1.6 RESEARCH HYPOTHESIS:
1.6.1 The lower the knowledge on transmission and prevention of cholera the poorer the practice
1.6.2 Negative attitude towards cholera lead to poor practice towards prevention of cholera.

1.7 SIGNIFICANCE OF THE STUDY:
The research work is important in several ways both to the Health personnel and the individuals within the society.

Firstly, this study will expose to us some of the causes of cholera outbreak in Ilorin and also proffer ways of preventing cholera outbreak within our community.
This study will also be of importance to the health personnel and our community health workers in the sense that it will expose to them the various preventive measures to put in place to avoid cholera outbreak in our community and Kwara State at large.
This study is also to be relevant to the government by providing the number of cholera outbreak within the Nigeria economy and also presenting the figures of victims who dies as a result of this disease, by this the government will swing into action by providing various measures in other to prevent further outbreak of the disease.