Sometimes incorrectly called the “dirty hands” disease, cholera is more accurately a disease caused by dirty water. The most serious cholera epidemics occur in areas where access to clean water and proper sanitation is lacking.
Louis Pasteur said it long ago: “We drink 90% of our diseases.”
Vaccines do exist, but they remain relatively ineffective, especially in children under the age of 5, and their use is extremely limited.
Thierry Vandevelde, Executive Officer of the Veolia foundation
Tackling the causes
For Thierry Vandevelde, Executive Officer of the Veolia foundation, “the real lasting solution to epidemics of cholera and other water-borne diseases therefore lies in strengthening access to hygiene, water and sanitation. This hygiene-based approach is greatly facilitated today by advances in epidemiology1, making it possible to identify where these epidemics begin: source areas (or hot spots). We can therefore better target the response and make it efficient by focusing efforts on these few target areas and promoting a multisectoral approach. Accordingly, from the outset, the DRC devised a plan ••• involving the Ministries of Health, Finance and Planning, along with Regideso (the national water utility company).”
2007, the Veolia foundation has been supporting evaluation work with a view to understanding how cholera and other water-borne diseases in the country spread. This work is based on the results of scientific research carried out by the epidemiologist Didier Bompangue2, published in 2009, which clearly establish a correlation between the development of cholera and a lack of access to drinking water. They also identify eight source areas in the east of the DRC. On the basis of these findings, in 2010 the government officially launched a Strategic multisectoral plan to eradicate cholera and combat diarrheal diseases (PMSEC-MD). It has chosen to rely on a “magic square,” i.e. a strengthened partnership with four stakeholders: the Congolese ministries, local NGOs, experts in urban water and energy infrastructure, and international backers. Eight major regions have therefore been methodically protected in order to better delineate some thirty health zones3 subject to increased surveillance. The aim is to define and then implement a prevention and response approach to cholera epidemics. These zones are all located in the east of the country, around lakeside regions conducive to the development of bacteria.
Understanding in order to act
Aurélie Jeandron - 伦敦卫生与热带医学院研究员
Doctor Didier Bompangue, the man behind this first plan, has since been appointed by the Minister of Health as Coordinator of the National program to eradicate cholera and combat diarrheal diseases (Pnechol-MD). He recalls that at the time, he “thanked Doctor Vandevelde for daring to trust [his] approach and that of [his] epidemiologist colleagues from Besançon University, when no one had yet clearly understood what we were working on.” Eight missions on the ground were organized with the Veolia foundation between July 2005 and March 2009.
With the support of the ministry, “we patiently created an epidemiological surveillance system thanks to a host of partners who enabled us to check our hypotheses on the ground. Especially those to geographically determine the priority research zones. Nowadays, this system allows us to have databases updated on a weekly basis,” highlights the epidemiologist.
This surveillance system shows that people living near a lake in the DRC are 7.5 times more at risk of being affected by the disease. Such as the inhabitants of Kalemie and Uvira, on the banks of Lake Tanganyika, which are key permanent source areas of cholera4. Working in these two cities, the Veolia foundation is putting forward a two-step strategy. First of all, understanding how the disease spreads.
“The solution may therefore lie in better access to water at certain points, and sanitation elsewhere,” Thibault Constant, the foundation’s project officer, reminds us.
In a second phase, sanitary hydraulic master plans promoting access to water and epidemic control are drafted collaboratively, involving experts from Veoliaforce, Congolese epidemiologist physicians, Regideso’s hydraulic engineers and NGOs on the ground.
A hot topic
These plans are leading to the implementation of infrastructure work. Already well advanced in Kalemie (355,000 inhabitants5), in partnership with the NGO Solidarités International, the work is beginning in Uvira (400,000 inhabitants), in South Kivu, with the support of the British NGO Oxfam and Regideso. It also benefits from eight million euros in funding from the French Development Agency, the European Union and the Veolia foundation. The results are already tangible in Kalemie, which offers improved access to high-quality water at access points and at home. This has led to a rise in the number of customers, strengthening Regideso’s self-financing capacity, a sign of the modernization and development of new water and sanitation infrastructure. Nonetheless, despite the investment already made and the multisectoral coordination in place for a decade under the authority of the National committee for action on water, hygiene and sanitation (CNAEHA), eradicating cholera remains a hot topic. Between the beginning of 2017 and the end of August, the DRC recorded 528 deaths in almost a third of its 26 provinces. “We must continue our joint efforts and be able to collectively fund the construction of water production plants and wastewater networks, not forgetting education, as a hygiene solution,” analyzes Thierry Vandevelde. Entirely in line with this conviction, Dr. Bompangue states that, “this crisis shows more than ever the need to work in depth on its structural reasons.”
Key figures on cholera
The figures are complex: in 2016, 132,121 cases were reported to the WHO by 38 countries, with a mortality rate of 1.8% (source: Weekly Epidemiological Record 2017, 92, 521-536). The estimates established by epidemiologist physicians speak of four million cases worldwide et and 21,000 to 143,000 deaths each year.
Cholera in brief This acute diarrheal infection, which can prove fatal within several hours if it is not treated, is caused by the ingestion of food or water contaminated by the bacillus Vibrio cholerae (Source: WHO). Find out more: www.fondation.veolia.com/en
1- Epidemiology is a scientific discipline that studies the frequency of diseases and their distribution, risk factors and mortality. (Source: FuturaSanté).
2- Didier Bompangue, “Dynamique des épidémies de choléra dans la région des grands lacs africains : cas de la République démocratique du Congo.” Ecology, Environment. Franche-Comté University, 2009
3- Out of the DRC’s 515 health zones. Source: National Sanitary Development Plan PNDS 2011-2015.
4- Source: Veolia foundation, find out more: www.fondation.veolia.com/en
5 – 2013 data.