KANO, 14 September 2010 (IRIN) - Poor diagnostics and weak surveillance are hampering government efforts to stem cholera in Nigeria says a government health worker.

The disease is most severe in the north; as of 8 September 781 people have died and 13,000 cases were reported. Onyebuchi Chukwu, Nigeria's health minister, said Katsina State in northern Nigeria had the highest number of cases - 3,310 infections and 175 deaths.

Isa Sadiq Abubakar, a consultant epidemiologist at Aminu Kano Teaching Hospital in the northern city of Kano, noted that northern Nigeria had good cholera surveillance systems but they were not being used properly.

Nigeria uses an Integrated Disease Surveillance and Response [IDSR] system, set up a decade ago to more effectively combat communicable diseases - such as yellow fever, meningitis and cholera - by training and equipping health staff to improve disease detection and response. "But staff training has been slow to deliver, and most health centres still lack the necessary equipment to accurately diagnose cholera," Abubakar noted.

Despite the high prevalence of cholera, many health workers still do not think of cholera when patients come with diarrhoea and dehydration, as they "don't have a high index of cholera suspicion", he said.

"Health workers do not know that mere diarrhoea calls for cholera investigation; cholera is an epidemic-prone disease, and Disease Surveillance and Notification Officers [DSMO] from local government primary healthcare level have been trained, but the training has not permeated down to the health workers."

Undiagnosed

Cholera recurs regularly in Nigeria – 13,000 cases were reported in 2009 – but in 2010 the disease has been spreading much more quickly, said Claire Lise Chaignat, coordinator of the World Health Organization's cholera response group.

Despite its prevalence, only a few private clinics and six teaching hospitals in northern cities – Zaria, Jos, Kano, Maiduguri, Sokoto, and Ilorin – have the microscopes that can diagnose cholera. Laboratory technicians identify cholera by examining stool samples under a microscope.

Abubakar said that health centres are supposed to send stool samples to these hospitals for diagnosis but many lack the biological cultures required to preserve them properly, and so they do not send them at all.

As a result, most health workers diagnosed cholera on clinical observation of symptoms, rather than laboratory evidence, or did not diagnose it at all. Sometimes the problem was very simple: they had run out of reporting formS. "Health workers have to use their [own] money to photocopy reporting formS, so they get fed up and abandon the process," Abubakar commented.

The lack of information from these healthcare units meant "outbreaks worsen and get out of control before health authorities get to know what is happening" Chukwu told IRIN.

A quick response was vital to stemming a cholera outbreak, said WHO's Chaignat. "With cholera, you have to react very quickly. By the time health workers have diagnosed the disease, it could be too late already."

Most cholera surveillance is supported WHO, which provides health centres with equipment for diagnostics, and diarrhoeal disease kits that include intravenous fluids and iodine tablets.

Denial

"Another setback to surveillance is official denial," said Abubakar. "When an international event is taking place in the country - say, a soccer tournament - the government will deny an outbreak for fear that acknowledging it will deprive it of hosting rights."

Health minister Chukwu said people should take more responsibility for improving their hygiene practices. "The disease is spreading rapidly despite measures taken to control it because people have refused to take personal hygiene seriously," he told IRIN.

"A lot needs to be done," Abubakar said. "There has to be improvement in sanitation, food and personal hygiene; refuse, sewage and drainage systems; as well as vigorous health promotion activities in terms of continuous public enlightenment on cholera."

The trouble is knowing where to start. "Health systems need to be strengthened; adequate manpower, equipment, drugs and consumables should be provided. Surveillance systems, communication and transport should be improved ... Mechanisms for quick intervention should be put in place ... and messages to prevent cholera should spread through health education."