Potential threats of cholera amidst COVID pandemic in the Democratic Republic of Congo; bridging the gaps: a review

Abstract

Cholera, being a global health issue has remarkably affected the wellness of the people, especially in the Democratic Republic of Congo (DRC). This has worsened during the COVID-19 pandemic, and it could be more if no concrete Intervention is done to curtail the outbreak. The authors reviewed past and present literatures on cholera and COVID-19 from the year 2013–2023 in well renowned scientific journals such as PUBMED, ResearchGate, Google Scholar. Database servers of these journals were accessed based on their permissions. From this search the authors found that, cholera is at its peak amidst COVID in DRC. Between the 10 March 2020 to the 10 March 2022, DRC reported a total of 86 462 cases of COVID-19 in 314 health zones in all 26 provinces of the country, with 1335 deaths recorded. And since the beginning of 2022, 6692 suspected cholera cases including 107 deaths have been reported in 54 health zones in 11 provinces of DRC, compared with 3681 suspected cases and 91 deaths reported during the same period in 2021 in 67 health zones in 14 provinces in the country. The authors realized that despite all efforts to mitigate the spread of cholera in DRC by the Congolese government and the non-governmental organizations in the country, there are still some gaps required to be filled, such as; limited community mobilizations and awareness campaigns about the signs and symptoms of cholera and COVID-19, unavailability of free cholera and COVID-19 vaccines to all the Congolese populations as well as association of witchcraft to diseases. etc. Hence, to mitigate this menace, the authors urge the Congolese government to utilize research implementation strategies such as increase mass awareness campaigns on cholera and COVID among the Congolese populations as well as training workshops for the religious and traditional leaders as well as the healthcare providers in the country for a better diagnosis and treatment of these diseases.

Introduction

Highlights

• Cholera is a global health issue which has remarkably affected the wellness of the people, especially in the Democratic Republic of Congo (DRC) and has worsened during the COVID-19 pandemic.

• Between the 10th of March 2020 to the 10th of March 2022, the DRC reported a total of 86 462 cases of COVID-19 in 314 health zones in all 26 provinces of the country, with 1335 deaths recorded.

• Also, since the beginning of 2022, 6692 suspected cholera cases including 107 deaths have been reported in 54 health zones in 11 provinces of DRC, compared with 3681 suspected cases and 91 deaths reported during the same period in 2021 in 67 health zones in 14 provinces in the country.

• Despite all efforts to mitigate the spread of cholera in DRC by the Congolese government and the non-governmental organizations in the country, there are still some gaps required to be filled, such as; limited community mobilizations and awareness campaigns about the signs and symptoms of cholera and COVID-19, unavailability of free cholera and COVID-19 vaccines to all the Congolese populations as well as association of witchcraft to diseases. etc.

• To mitigate this menace, we urge the Congolese government to utilize research implementation strategies such as increase mass awareness campaigns on cholera and COVID among the Congolese populations as well as training workshops for the religious and traditional leaders as well as the healthcare providers in the country for a better diagnosis and treatment of these diseases.

Despite efforts to mitigate the spread of cholera in the world, cholera still remains a global public health threat in some parts of the world, especially in the Sub-Saharan region, where the DRC falls into. Cholera is an indicator of the lack of equity and poor social development in the African sub-region1. Cholera is an acute diarrhoeal infection caused by the consumption or ingestion of food or water contaminated with the bacterium Vibrio cholerae. Being an infectious disease, it could be deadly within hours if left untreated for special populations such as the under-five children and the pregnant women2. The epidemiological situation in DRC is marked by a remarkable increase in diseases with epidemic potential, which have destabilized and paralyzed the health system3. Over the past few years, DRC has experienced several epidemics, including Ebola, bubonic plague, meningitis, cholera and other infectious diseases2. The first case of COVID-19 in DRC was reported in its capital Kinshasa by the Minister of Public Health, Hygiene and Prevention and on the 10th of March, 2020, it was declared an epidemic in DRC3,4. Amidst the COVID-19 pandemic, which has caused a major health crisis worldwide. Unfortunately, the DRC faced another outbreak of cholera in the country which therein compounds the existing problems due to the Covid-19 pandemic. Problems like poor knowledge, attitudes, and perceptions of the Congolese populations on cholera and Covid-19, misdiagnoses of cholera from Covid-195 by the healthcare providers in DRC, limited diagnostic kits, treatment facilities in the country, economic crises, conflicts, and little political will by the Congolese government regarding the eradication of cholera and other infectious diseases like Covid-19 are some of the major threats on ground6, which this present study aimed to address this.

Current situation of Cholera and COVID-19 in DRC

While the world keeps its eyes riveted on the COVID-19 pandemic, old public health scourges still ravage in silence and thousands of people suffer. This is the case of cholera and other diarrhoeal diseases in Africa, for example, the DRC. Between the years 2013 and 2017, DRC reported ~151 000 cases and 3,304 deaths from cholera. In the years 2018 and 2019, the number of suspected cholera cases was quite similar, but in 2019 the number of deaths decreased by 51% compared with 2018. Between January and the beginning of October 2020, the number of suspected cases and the number of deaths decreased by 30% compared with the same period in 20197.

Since the beginning of 2022, 6692 suspected cholera cases including 107 deaths have been reported in 54 health zones in 11 provinces of the country, compared with 3681 suspected cases and 91 deaths reported during the same period in 2021 in 67 health zones in 14 provinces. A significant increase in the number of suspected cases and deaths from the disease in 2022 compared to 20218. COVID-19 disease, which was first identified in Wuhan, China, in September 2019, has been spreading around the world at an alarming rate since its inception9. The WHO declared a global pandemic in March 2020. Between the 10 March 2020 to 10 March 2022, a period of 2 years, DRC reported a total of 86 462 cases of COVID-19 in 314 health zones in all 26 provinces of the country, with 1335 deaths recorded, representing a case-fatality rate of 1.5%, as well as 64 656 people cured. In total, 816,524 people were vaccinated with more than 14,637,900 doses of vaccine were delivered to the country3.

Efforts and Implications to fight against Cholera and COVID-19 in DRC

Cholera, being a communicable disease, has a contagious rate among family members due to the hygiene practices of the family. This is the same in the case of COVID-19 as close family members could contract the disease from one another. Therefore, curtailing the spread of Cholera and COVID-19 should with from the family. Early diagnosis and monitoring of patients of family members could help reduce the outbreak of these diseases. A study conducted in an area affected by cholera in the DRC concluded that the distribution of hygiene kits to families of patients with the disease could reduce the spread of the disease10.

In any outbreak, the families are most affected, with loss of lives due to the disease and the risk of increased spreading of the disease11. Children and mothers are at high risk of contracting the disease. Since the onset of the COVID-19 pandemic, there have been an increased rate of goods and services in most parts of the world, including the DRC. In lieu of this surge in the inflation rate, an outbreak of cholera could affect the economy of DRC further12. In a report by the United Nations of Children Emergency Fund (UNICEF), many households in DRC with confirmed cases of Cholera expressed how the disease reduced their income and might affect their social status in the community. Also, how handwashing might be difficult due to the cost of soaps and detergents and the accessibility to good sources of water8. As many of these communities affected by cholera, do not have access to clean and affordable water.

Although, the governments of the DRC and Médecins Sans Frontières made efforts in the distribution of hygiene kits to community members, construction of healthcare facilities, Cholera Treatment Units and Oral Rehydration Points in the country, however, these efforts, perhaps were not well implemented or were sabotaged13. The association “SOLIDARITÉS INTERNATIONAL” also made efforts in North Kivu, an endemic town to Cholera in the DRC. They constructed public latrines and distributed hygiene kits to both Masisi and Kirotshe Health Zones14. These efforts too were not good enough as there were gaps in the implementations. Most of the rural dwellers could not benefit from the services. Exploring some recent breakthrough, we found that the Global Task Force on Cholera Control are aiming on ending 90% of Cholera by 2030 in DRC and has started efforts to eliminate cholera in 20 countries by 2030. These are some of the efforts made so far in the elimination of cholera in the DRC10–15.

Cholera surveillance should be part of an integrated disease surveillance system with local feedback and global exchange. Cholera-affected countries are advised to strengthen disease surveillance and national preparedness for early detection of potential outbreaks and to intervene to prevent the next cholera outbreak. Insufficient access to safe drinking water is a major factor in the occurrence of cholera and cholera cases are detected based on presumptive clinical diagnosis in patients presenting with severe acute watery diarrhoea, and samples are analyzed in a laboratory for confirmation by bacterial culture. This leads to the improvement of treatment infrastructure and water production and sanitation facilities. Strengthening diagnostic and sample analysis facilities is also important for the control of COVID-1916.

Community involvement and hygiene awareness are also essential for the fight against cholera and the COVID-19 pandemic, so this community mobilization must develop and implement programs to combat these two scourges of DRC health system. Cholera can be prevented by adopting appropriate hygiene practices, such as handwashing with soap, safe food preparation and storage, and safe disposal of children. To respond effectively to the COVID-19 and cholera pandemic, the Congolese government and its Ministry of Public Health, Hygiene and Prevention, in collaboration with its partners including the WHO and the Centers for Disease and Prevention Control (CDC), mu develop an emergency plan that will allow for an effective response and management of patients against COVID-19 and cholera. This plan must be taken into consideration. Such as; coordination, epidemiological surveillance, health control at the country’s entry and exit points and the most affected regions, medical management of these scourges, the laboratory, prevention and control of COVID-19 and cholera, logistics, vaccination against COVID-19, risk communication and community involvement14,15.

Recommendations and the way forward

The identification of the bacterium Vibrio cholerae is carried out in a specialized medical laboratory, by the analysis of stool samples from patients suffering from cholera, it is the same case concerning COVID-19. The rapid detection of cholera and COVID-19 is facilitated by the use of rapid diagnostic tests and an alert must be triggered if a sample is found to be positive for these two pathologies17–19. Thus, we recommend the Congolese government to properly equip its health structures, especially those located in the regions most affected by cholera, and strengthen local capacities to diagnose, collect and analyze data from cholera cases to ensure the effectiveness of the surveillance system and plan control measures. These same elements will not only be effective in the eradication of the COVID-19 pandemic on the national territory of DRC, but also surveillance of these two diseases (cholera and COVID-19) should be part of an integrated disease surveillance system.

To combat cholera and COVID-19 and to lower the mortality rate that these two pathologies cause, surveillance and response measures must be used by combining the surveillance of these diseases, the improvement of the supply of drinking water, sanitation and hygiene, social mobilization and good care for patients affected by these diseases16. The provision of safe water and sanitation services is paramount and a long-term solution to combat the transmission of cholera and COVID-19. The WHO recommends the provision of sufficient, safe water and adequate sanitation and hygiene as very paramount in preventing cholera8. The Congolese government should therefore ensure the availability of clean water to all the Congolese population in the country at a cheaper rate. More Primary healthcare facilities should also be built and made available in an efficient way by the Congolese government in handling cases of Cholera and COVID-19 in the country. Also, the Congolese government should provide more availability of water purifiers for free to all the Congolese community members that are most affected by cholera These community members should be taught how to make use of them, and how to practice regular handwashing by well-trained healthcare providers especially the Community Health Extension Workers (CHEWs) in the country.

The health authorities in DRC should facilitate the construction of good and sophisticated latrines in the Congolese government in communities affected by cholera. Similarly, the Congolese government should strengthen its policy on open defecation and throwing dirt in water bodies in all the rural areas in DRC by laying more emphasis on health campaigns such as “#say-no-to-open-defecation”, “#stop-open-defecation-in-DRC”, etc. This policy should be well implemented through research implementation strategies on cholera by the physicians, nurses, and CHEWs including the social workers in DRC. Other research implementation strategies for cholera, control includes; ensuring safe piping, monitoring of sachet water and water bottling companies by the Congolese government, as well as the establishment of more training workshops, seminars, etc. to train the CHEWs to efficiently communicate to members of the society on ways to prevent these diseases (Covid-19 and cholera). Furthermore, the Congolese government should work hand-in-hand with the community leaders and religious leaders in DRC to help disseminate information on the prevention of these diseases to the community members especially during religious and cultural events. Teachers and school management in the DRC should ensure the safety of water and food in schools and proper hygiene should be added to the curriculum and taught to students.

Communication about potential risks, and symptoms of COVID-19 and cholera, precautions to take to protect against these two diseases, when and where to report cases, and the need for a consultation immediately when symptoms appear. Social media, for example. Facebook, Instagram, Twitter, Linkedln, etc. and text messages should be used to reach a wide number of people. Hence, the Congolese government should provide a very good internet connection and WIFI in the country, especially in rural areas. Use of emergency hotlines with shortcodes that can be easily remembered and to which cases can be reported immediately should be provided by the Congolese government as it has been done in the Western world20.

Finally, we recommend community mobilization and awareness campaigns on cholera and Covid-19, especially on the preventive measures and the signs and symptoms among the Congolese populations by the civil organizations in DRC. The community members should be involved in the development of programs for these two medical conditions. As there is a need for rural enlightenment about these diseases. Also, the association of these diseases with witchcraft should be preached against by the physicians, nurses, and CHEWs in the country. Moreso, the Congolese government should implement the administration and wide coverage of free Cholera and COVID-19 vaccines for the benefit of the entire Congolese population in other to prevent future outbreaks of COVID-19 and cholera in the country.

Conclusion

Cholera, being an acute diarrhoeal infection, is caused by the consumption or ingestion of food or water contaminated with the bacterium Vibrio cholerae. It remains a global public health threat and an indicator of the lack of equity and poor social development in the African sub-region. And while the world keeps its eyes riveted on the COVID-19 pandemic, old public health scourge like cholera still ravages in silence and thousands of people suffer. These diseases have a negative impact on the economy of these communities. The outbreak has further affected the finances of individuals in these communities which may make them poorer. Hence, to mitigate these outbreaks of these diseases, more emphasis should be made on community mobilizations, awareness campaigns about the signs and symptoms of these diseases, provision of free vaccines to all the Congolese populations including the provision of well-equipped health structures by the Congolese government especially to those located in the regions of the country most affected by cholera and COVID-19. All these would strengthen local capacities to diagnose, collect and analyze data from cholera and COVID-19 cases in order to ensure the effectiveness of the surveillance system and plan control measures in the country.

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Source of funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author contributions

Conceptualization: A.A. and S.B., funding acquisition: M.K.M. and G.M., investigation: H.C., project administration: A.A., resources: A.B., software: P.B. and I.M., supervision: S.B., validation: G.R., visualization: M.O.O., writing—original draft: C.B., L.K., K.B., G.R. and B.M., and writing—review and editing: M.O.O. Final approval of manuscript for publication; All authors.

Conflicts of interest disclosure

The authors have no competing interests to declare that are relevant to the content of this article.

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Chrispin Biamba.

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