CONAKRY, 12 December 2011 (IRIN) - With just two cholera cases reported in 2011, Guinea escaped an epidemic in West and Central Africa that infected 85,000 people and killed 2,500 in the first 10 months of 2011.  Luck, as well as targeted prevention efforts on the part of aid agencies and the government brought this about, specialists told IRIN, but a far deeper countrywide overhaul of the water and sanitation system is needed to diminish the likelihood of future outbreaks.

After widespread cholera infection in 2009, the government and aid agencies boosted prevention efforts in Guinea, making chlorine to sterilize water more readily available, spreading hand washing and clean water storage messages, and improving access to drinking water in schools and villages. These efforts have paid off: the absence of "cholera is one of the few highlights" this year, said Julien Harneis, head of the UN Children's Fund (UNICEF) in Guinea.

Fish faeces and hand washing

Prevention is working better than in the past partly because aid agencies have developed a more sophisticated understanding of what drives the disease. In coastal areas of Guinea, including the capital, Conakry, fish proved to be an effective cholera host, passing it on through their faeces at markets across the city.

Cases dropped significantly once fish storage and transportation were cleaned up. "Approaches to cholera treatment and prevention are more sophisticated now, and are based on a more in-depth scientific understanding," said Harneis, who recently returned from a regional workshop in the Senegalese capital, Dakar, on how the disease is spread in the region.

A cholera emergency contingency team - made up of representatives from the Ministry of Health, the International Committee of the Red Cross, administrators from the principal hospital, Donka, NGOs such as Action Contre la Faim (ACF) and UN agencies, including UNICEF - now meets regularly to discuss early warning and response.

Hygiene practices and access to clean water are the main problems in Guinea. One marker of poor hygiene practices is that diarrhoea prevalence is similar in areas with high or low access to clean water, and in Conakry it is double that in rural regions. "The vast majority of people use unsanitary shared latrines... and the seaside is used for defecation in large parts of the city," said Lalit Patra, head of water, sanitation and hygiene (WASH) at UNICEF in Guinea.

ACF tackles cholera by using street theatre to educate residents in at-risk neighbourhoods in cholera prevention, backed up by house-to-house visits where they distribute hygiene kits and give further advice.

In Matoto, northeast Conakry, an actor representing cholera infects all who approach him. In the question and answer session after the show, another actor asks the audience of mainly women and children, "How can someone be infected by cholera?" A woman grabs the microphone to answer: "With dirty hands, and when you don't store your water well."

Hand washing and other hygiene practices have improved. "People are doing better - they wash their hands, there are more toilets in schools, but there remains too much to do," Hawa Touré, Joint Director of Community Health at the Ministry of Health, told IRIN.

No water surveillance

Emergency prevention and response in Guinea are working well, but a more holistic water and sanitation strategy is needed to prevent future outbreaks, Patra told IRIN.

Cholera is unlikely to disappear anytime soon - the nature of the disease in the region has changed to become "hyper-endemic", meaning it is ever-present, with regular peaks, say aid agencies.

There has been no systematic water quality surveillance in Guinea to date, but it is highly likely to be polluted, as sources are not protected and sewage can enter pipes.

The work of aid agencies such as ACF and UNICEF has had an impact. UNICEF has helped build water points and latrines in schools, and has worked with communities in 120 villages to discourage open defecation but Patra said more resources are needed to scale up such work throughout the country, and access to clean water should be made cheaper.

The government, private sector and large agencies have traditionally turned to drilling boreholes as the answer to a lack of water, but at $10,000-$12,000 per borehole this approach is very expensive. Cheaper solutions include using local equipment to manual drilling - successfully tried in Chad and Democratic Republic of Congo - installing hand-pumps, or building water pipe systems in mountainous regions. "I was shocked that nothing else had yet been tried here," Patra told IRIN.

Trying alternatives will not be easy. Trainers will have to be imported from abroad and a monopoly of French and Germany manufacturers will need to be dismantled, said Patra, who suggests India as a cheaper alternative, based on his experience in promoting governance and community management of locally appropriate WASH technologies in Bangladesh, Indonesia and India.

Bold steps are needed to keep Guinea cholera-free in the long term. As Harneis put it: "We have been lucky... but whether or not we get cholera next year - that will be the real lesson."

Source:  Integrated Regional Information Networks (http://www.irinnews.org )