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Cholera Epidemiology and Response Factsheet GHANA CHOLERA EPIDEMIOLOGY AND RESPONSE FACTSHEET GHANA CHOLERA OVERVIEW Cholera was first reported in Ghana in 1970. Since 1990 and up to 2010, the overall yearly trend showed a decrease over time in size. However, there have been large outbreaks in 2011 and 2012 and cases have been reported each year (Fig. 1). Between 1998 and 2013, epidemiological surveillance reported 55,784 cases with 1,095 fatalities (case fatality rate ≈ 2%) 1 . Main outbreaks were reported in the densely populated regions of Greater Accra and Ashanti, and in bordering coastal regions. Ghana is affected by cross-border outbreaks mainly from Nigeria and Togo, especially along the Guinea coast. CHOLERA DISTRIBUTION The four regions along the coast, Greater Accra, Central, Western and Volta represent over 70% of cholera cases between 1998 and 2013. This is driven by large outbreaks in Greater Accra region. In the middle of the country, the main outbreaks were recorded in the densely populated Ashanti and Eastern regions which border Greater Accra region, with nearly 18% of registered cases. In the North of the country, less than 10% of cholera cases were reported. Outbreaks in Greater Accra, Central and Eastern occured at similar times-all-year round and were connected as a result of movement between these regions. Separate sporadic outbreaks in other regions appeared to be seasonal, emerging around June and September for Ashanti region and the northern part of the country. These seemed to coincide with rainy seasons and festivals when there was increased movement within and between regions. Outbreaks in Ghana usually spread towards neighbouring countries from the south of Cameroon to Guinea Bissau through migrant fishermen and commercial trade. Figure 1. Yearly number of cholera cases and case fatality rate (CFR) in Ghana, 1990–2013 1 Figure 2. Cumulative incidence of cholera by commune in Ghana, 1998–2013 2 Figure 3. Weekly number of cholera cases and median of estimated ten-day precipitation in Ghana, 2001–2013 2,3 Table I. Epidemiological parameters of cholera outbreaks by main affected region in Ghana, 1998–2013 2 Note. [1] Total cases = 52,369 and total deaths = 263 between 1998 and 2013; [2] Average in weeks between 1998 and 2013. Missing data for 2003, 2006, 2008 and 2009. Area Cases / Deaths [1] % of total cases Number of outbreaks Duration [2] GREATER ACCRA 27,953 / 120 53.4 8 65 ASHANTI 5,146 / 99 9.8 10 12 CENTRAL 5,032 / 0 9.6 9 35 EASTERN 4,194 / 8 8 9 26 UPPER EAST 3,688 / 5 7 5 8 VOLTA 2,703 / 9 5.2 13 15 WESTERN 1,702 / 6 3.2 10 16 BRONGA-AHAFO 997 / 13 1.9 6 11 NORTHERN 954 / 3 1.8 8 8 Number of cases Case fatality rate Note. Missing data for 2003, 2006, 2008 and 2009.

CHOLERA EPIDEMIOLOGY AND RESPONSE FACTSHEET GHANA - UNICEF · • at the border with Togo on the coast (Ketu). Figure 4. 2Cholera pattern for health districts in Ghana, 1998–2013

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Cholera Epidemiology and Response Factsheet GHANA

CHOLERA EPIDEMIOLOGY AND RESPONSE FACTSHEET GHANA

CHOLERA OVERVIEW

Cholera was first reported in Ghana in 1970. Since 1990 and up to 2010, the overall yearly trend showed a decrease over time in size. However, there have been large outbreaks in 2011 and 2012 and cases have been reported each year (Fig. 1).

Between 1998 and 2013, epidemiological surveillance reported 55,784 cases with 1,095 fatalities (case fatality rate ≈ 2%)1.

Main outbreaks were reported in the densely populated regions of Greater Accra and Ashanti, and in bordering coastal regions.

Ghana is affected by cross-border outbreaks mainly from Nigeria and Togo, especially along the Guinea coast.

CHOLERA DISTRIBUTION

The four regions along the coast, Greater Accra, Central, Western and Volta represent over 70% of cholera cases between 1998 and 2013. This is driven by large outbreaks in Greater Accra region.

In the middle of the country, the main outbreaks were recorded in the densely populated Ashanti and Eastern regions which border Greater Accra region, with nearly 18% of registered cases.

In the North of the country, less than 10% of cholera cases were reported.

Outbreaks in Greater Accra, Central and Eastern occured at similar times-all-year round and were connected as a result of movement between these regions. Separate sporadic outbreaks in other regions appeared to be seasonal, emerging around June and September for Ashanti region and the northern part of the country. These seemed to coincide with rainy seasons and festivals when there was increased movement within and between regions.

Outbreaks in Ghana usually spread towards neighbouring countries from the south of Cameroon to Guinea Bissau through migrant fishermen and commercial trade.

Figure 1. Yearly number of cholera cases and case fatality rate (CFR) in Ghana, 1990–20131

Figure 2. Cumulative incidence of cholera by commune in Ghana, 1998–20132

Figure 3. Weekly number of cholera cases and median of estimated ten-day precipitation in Ghana, 2001–20132,3

Table I. Epidemiological parameters of cholera outbreaks by main affected region in Ghana, 1998–20132

Note. [1] Total cases = 52,369 and total deaths = 263 between 1998 and 2013; [2] Average in weeks between 1998 and 2013. Missing data for 2003, 2006, 2008 and 2009.

AreaCases / Deaths

[1]

% of total cases

Number of outbreaks

Duration [2]

GREATER ACCRA 27,953 / 120 53.4 8 65

ASHANTI 5,146 / 99 9.8 10 12

CENTRAL 5,032 / 0 9.6 9 35

EASTERN 4,194 / 8 8 9 26

UPPER EAST 3,688 / 5 7 5 8

VOLTA 2,703 / 9 5.2 13 15

WESTERN 1,702 / 6 3.2 10 16

BRONGA-AHAFO 997 / 13 1.9 6 11

NORTHERN 954 / 3 1.8 8 8

Num

ber o

f cas

es

Cas

e fa

talit

y ra

te

Note. Missing data for 2003, 2006, 2008 and 2009.

CHOLERA HOTSPOT IDENTIFICATION

Outbreak onset and cross-border spread are mainly occurring in Greater Accra, Central, Eastern and Western regions and less often in Volta and Ashanti (Fig. 4 and Tab. II).

Overall, districts regularly affected and with a medium to high duration or incidence are located (Tab 3):• in Greater Accra region and neighbouring coastal and inland dis-

tricts;• on the coast, in and around Cape Coast Municipality;• inland, in and around Kumasi Metropolis;• at the border with Togo on the coast (Ketu).

Figure 4. Cholera pattern for health districts in Ghana, 1998–20132

Table II. Summary of cholera hotspots classification and strategic interventions in Ghana, 1998–20132

Note. Missing data for 2003, 2006, 2008 and 2009. Type 1 (T.1): High priority area with a high frequency (>90th percentile) and a long duration (>40th percentile). Type 2 (T.2): Medium priority area with a moderate frequency (between 80th–90th percentile) and a long duration (>40th percentile). Type 3 (T.3): Medium priority area with a high frequency, short duration (< 40th percentile) and a high incidence (> 40th percentile). Type 4 (T.4): Low priority zone with moderate frequency, short duration and a high incidence.

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References1. Global Health Atlas, WHO: http://apps.who.int/globalatlas.2. Ministry of Health Ghana, 1998–2013 cholera data. Missing data for

2003, 2006, 2008 and 2009.3. FEWSNET (Famine Early Warning Systems Network: http://www.fews.net).

4. Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS), 2012: http://data.unicef.org/water-sanitation/sanitation.

5. Cholera outbreaks investigation reports, Ministry of Health Ghana.6. WASH and Cholera in Ghana, positioning paper, UNICEF, 2015.

AcknowledgementsDzotsi E., MD, Addo J., Ministry of Health Ghana, Dunoyer J. (coordina-tion, UNICEF WCARO), Sudre B., MD PHD (scientific advice), Green HK., PHD (data analysis), Rossi M. (spatial data management).

STRATEGIC RECOMMENDATIONS

High-risk cholera areas along the coastline are located on a corridor where outbreaks spread from and to neighboring countries, Benin, Togo, Nige-ria and IvoryCoast (Tab. II). It should be noted that the Central and the Northern regions bordering Burkina Faso can also be affected by cholera outbreaks. This highlights the importance of cross-border activities for coastal regions and to a less extend for districts bordering Burkina Faso. In Greater Accra region and bordering regions, preparedness and response plans should be developed and implemented including: (1) strengthening early detection and rapid response systems of which community based surveillance and cross-border alert; (2) setting up coordination mechanisms across the sectors and borders; (3) building capacity on outbreak manage-ment; (4) targeted pre-positioning of supplies and (5) preparing communica-tions messages and plans (Tab. II).

Sustainable Water, Sanitation and Hygiene activities should be a priority in districts regularly affected with long outbreaks (Tab. II,Type 1). An 2014 in-tegrated WASH-epidemiological study6 has been conducted by UNICEF in Great Accra Region and proposes to 1) initiate advocacy with Ghana Water Company Limited to improve the water quantity and quality provided to the poorest, 2) strengthen post-chlorination of the network by installing dosing chlorine pumps at strategic points along the network conduct, 3) promote the use of GIS technology during an outbreak to identify any stra-tegic hotspots in Accra, and 4) when hotspots are identified, implement WASH and Health development programs targeting identified communities and consider the use of Oral Cholera Vaccine.

Livelihood groups and high risk practices to be considered in preven-tion, preparedness and response strategies5: • densely populated informal settlements in Accra (slums), home of commercial traders from neighboring countries; • food and water sachets vendors in Accra; • Movement of workers between Eastern region and Great Accra region• trade and movement of workers between Volta region (Ketu district) and Togo (Lomé D4 and Golfe districts);• migrant fishermen communities traveling to coastal countries along the Guinean gulf; • traders and bus drivers on the coastal road Accra–Lagos.

Figure 5. Water and sanitation coverage estimates in Ghana, 1990–20124

REGION DISTRICT

Rec

urr

ence

(No

. of o

utb

reak

s)

Ou

tbre

ak

du

rati

on

(ave

rag

e in

wee

ks)

Mea

n in

cid

ence

(p

er 1

0,00

0 in

hab

.)

Em

erge

nce

(med

ian

on

set

wee

k [m

in–m

ax])

Cro

ss-b

ord

er

spre

ad

Ho

tsp

ot

typ

e

Ear

ly d

etec

tion

S

urv

eilla

nce

Prea

par

adn

es

WA

SH

-Ep

id.

Stu

dy

WA

SH

d

evel

op

men

t

Ro

le o

f va

ccin

atio

n

Cro

ss-b

ord

er

colla

bo

ratio

n

ASHANTI

ATWIMA 5 11 2 34 [29–43] No T.2 √ √ √ √ √

KUMASI METROPOLIS 5 13 4 33 [30–45] No T.2 √ √ √ √ √

BOSOMTWE-KWANWOMA 6 6 2 38 [10–41] No T.2 √ √ √ √ √

CENTRAL

GOMOA 5 7 1 34 [7–47] No T.2 √ √ √ √ √

MFANTSIMAN 6 11 6 29 [1–48] No T.2 √ √ √ √ √

ABURA- ASEBU-KWAMANKESE 7 6 2 24 [5–46] No T.1 √ √ √ √ √

CAPE COAST MUNICIPALITY 8 18 12 17 [1–45] No T.1 √ √ √ √ √

AWUTU-EFFUTU SENYA 9 15 5 20 [1–43] No T.1 √ √ √ √ √

KOMENDA-EDINA-EGUAFO-ABIREM 10 9 4 36 [8–52] No T.1 √ √ √ √ √

EASTERN

AKWAPIM SOUTH 5 6 4 14 [1–51] No T.2 √ √ √ √ √

EAST AKIM 6 7 3 33 [11–42] No T.2 √ √ √ √ √

NEW JUABEN MUNICIPALITY 6 7 6 33 [10–46] No T.2 √ √ √ √ √

MANYA KROBO 6 4 1 25 [3–48] No T.4 √ √

SUHUM-KRABOA-COALTAR 7 6 5 19 [11–51] No T.3 √ √

BIRIM NORTH 8 4 1 30 [2–49] No T.3 √ √

WEST AKIM 9 7 3 26 [7–46] No T.1 √ √ √ √ √

GREATER ACCRA 8 65 9 19 [1–52] Yes T.1 √ √ √ √ √ √

VOLTAKRACHI 5 4 2 33 [0–51] No T.2 √ √ √ √ √

KETU 9 15 3 35 [18–51] Yes T.1 √ √ √ √ √ √

Number of outbreaks

Ave

rage

of i

ncid

ence

rate

per

10.

000

inha

b./w

eek