Cholera Outbreaks in Conflict-Hit Regions of Northern Nigeria: An Overview

Cholera Outbreaks in Conflict-Hit Regions of Northern Nigeria: An Overview Bashar Haruna Gulumbe, Uzairu Aminu, Zaharadeen Muhammad U Yusuf , Usman Umar Liman,Abdullahi Adamu Faggo, Junaidu u Abubakar, Abdulrakib Abdulrahim, Nazeef Idris Usman Department of Microbiology,Faculty of Science,Federal University Birnin Kebbi, K Kebbi State, Nigeria. Department of Biochemistry, Faculty of Life Sciences, Alqalam University Katsina, K State, Nigeria Department of Biochemistry, Faculty of Science, Federal University Birnin-Kebbi, Kebbi State, Nigeria. Department of Microbiology, Bauchi State University, Gadau, Bauchi State, Nigeria.

Cholera, an acute diarrheal disease, remains a major public health problem, causing substantial morbidity and mortality in many developing countries. Cholera infection occurs when food or water is tainted with the etiologic bacteria, Vibrio cholerae. Nigeria has seen sporadic outbreaks of epidemic cholera since it first appeared in 1972. Recently, cholera cases have significantly increased since June 2022 and have been negatively impacted by floods, with outbreaks mostly occurring in the northern states. Between January to September 2022, Nigeria reports more than 10,000 probable cholera cases. As of December 24, 2022, cholera outbreaks have been reported in the Northeastern States of Borno, Adamawa, and Yobe. A total of 7,700 cases, including 324 deaths, were reported across these three states, with Borno State accounting for 70.13% of these cases. The spread of cholera and other waterborne diseases is likely to escalate due to factors such as flooding, limited access to hygiene services, and water contamination. Moreover, insurgency, which has devastated the Northeast and armed banditry in the Northwest, has displaced millions of people, limiting access to clean water and food. This situation has aggravated the outbreaks of cholera in the region leading to recurring outbreaks which are characterized by high mobility, increased hospitalization and deaths. However, the nature of the hostilities in the two regions makes it challenging to determine the precise burden of cholera due to reporting and access issues. Therefore, this article gives an overview of the cholera situation in the conflict-hit regions of Northern Nigeria in the hopes to create more awareness and facilitate the prevention strategies to contain the spread of cholera disease. Cholera, caused by Vibrio cholerae continues to pose a threat to public health globally and is a major sign of a lack of social progress. Most developing nations in the tropics and subtropics are currently affected. It is widespread throughout Africa, the Middle East, some regions of Asia, and South and Central America [1,2]. Natural disasters like floods fuel the pandemic by upsetting the natural order, which causes numerous health issues, including those related to food and water [3,4]. In  Recurring outbreaks of cholera have been reported in these regions. For example, as of 24 December 2022, 7,700 cases of cholera, including 324 deaths, were reported across the three northern states of Borno, Adamawa and Yobe, with 5,400 of these cases in Borno state alone [9]. Adamawa State currently has 124 cholera cases and 5 fatalities across six local government areas (LGAs), including Yola. An estimated 1,300 people have been affected across 12 LGAs [9]. In addition, the nature of the conflicts in the two regions creates a situation where the exact burden of cholera will be challenging to establish due to underreporting and a lack of access. In addition, cholera's two most distinctive epidemiologic characteristics are its propensity to manifest in violent outbreaks and to cause pandemics that may gradually afflict several nations. Therefore, this paper distils available literature to get an understanding of the cholera situation in the region. Moreover, challenges faced by government and nongovernmental eradication efforts and offered suggestions to help develop targeted infection control and prevention initiatives as also discussed.

Boko Haram attacks in the Northeast and banditry in the Northwest
Boko Haram is a militant Islamist group based in Northeastern Nigeria, recognized for its violent extremism and insurgency activities [10]. The group's name translates to "Western education is forbidden" in the local Hausa language, reflecting its opposition to anything it perceives as a Western-based influence, including secular education and governance systems [10]. The group was founded in 2002 by Mohammed Yusuf, initially as a non-violent religious movement, but it evolved into an armed rebellion following Yusuf's death in police custody in 2009, leading to the widespread violence and instability that characterizes the group today [10,11].
Communities in Nigeria's Northeastern provinces have been ravaged by the 14-year struggle with Boko Haram. Boko Haram has focused its attacks on both people and security forces while also causing significant damage to public structures and infrastructure. The frequent raids have seriously violated local residents' human rights. Murder, kidnapping, sexual assault, child conscription for forced labour, looting, and burning of public structures (like schools), private property (like farmland), and, in some cases, entire communities are among these atrocities [11,12]. The crisis is marked by bombing, kidnapping, and the devastation of lives and property. Boko Haram is related to bad government and religious fanaticism. Between 2009 and 2018, the Boko Haram conflict claimed over 30,000 lives, forced over 1.8 million people from their homes, and damaged property worth 16 billion naira [13]. The victims of this abuse frequently suffer from long-lasting physical and psychological anguish.
In the late 2000s, banditry in rural Nigeria started to spread. It has now developed into sophisticated violent crime, characterized by vastly influential syndicates operating across borders. According to the pattern of recent assaults in northern Nigeria, there is now an increased threat from terrorism, banditry, arms and illicit substance trafficking [14,15].
In northern Nigeria, there is evidence of a covert alliance between terrorist groups and bandits that is motivated by pragmatism or tactical opportunism. They had grown into organized tribes of semi-sedentary criminals by the late 2010s, maintaining little fiefdom in the underground. This was especially true in certain regions of the Northwestern Nigeria States of Zamfara and Katsina [14]. Numerous variables, including bandits' connections to Islamist fanaticism, narcotics, and arms trade, have allowed banditry to evolve into a sophisticated type of organized crime. Bandits are currently active in numerous states of Nigeria's Northwestern and North-central regions. Zamfara, Katsina, Kebbi, Kaduna, Sokoto, Nasarawa, and Niger are the key hotspots. With its epicentre in the Birinin Gwari neighbourhood, the Kaduna-Katsina-Zamfara axis has seen a disproportionately high number of fatal accidents. On March 28, 2022, robbers bombed a Kaduna-Abuja train's rails in an attempt to demobilize it for assault. The incident highlighted the banditry crisis's intractability and its worsening dynamics [14]. It is estimated that at least 200 people were slain in some of the bloodiest attacks by armed bandits operating freely in the communities in Zamfara State of Northwestern Nigeria [16].

Cholera situation in the Northeastern and Northwestern Nigeria
Cholera is one of the major opportunistic diseases. The rate of the outbreak in Northeastern and Northwestern Nigeria, especially in Borno, is alarming, with concentrated cases in Gwoza and Danboa LGAs. As of December 1, 2022, 75% of the reported 696 cases and 69% of the 46 fatalities from the outbreak were accounted for. Reliefweb recorded more than 2,000 instances of cholera in 25 local government areas in Borno, Adamawa, and Yobe states, with 76 fatalities; these LGAs were among those that were severely impacted by the Boko haram insurrection in 2021 alone [9]. According  According to the multi-sectoral needs assessment (MSNA) results, the most pressing needs in these states are WASH, education and shelter [4]. As priority is now being shifted towards security, a significant data concerning cholera outbreaks are limited and unavailable from most of the remote areas of Northeastern and Northwestern Nigeria, leading to underreporting.
The risk factors that have contributed to the rapid spread of the disease across the northeast and northwest of Nigeria are the limited health and water, hygiene, and sanitary (WASH) facilities, which have been further weakened by conflict in the region, poor hygiene practices, particularly open defecation, and congestion across camps and communities hosting displaced and affected population.

Armed conflict as a driver of cholera transmission
Armed conflict acts as a direct or indirect catalyst in the transmission and exacerbation of infectious diseases [19]. Armed conflict was connected to a 3.6-fold increase in cholera outbreaks in Nigeria, and over the past two decades, the cholera disease outbreak attributable to conflict in Nigeria is 19.7% [20]. Boko Haram and bandit attacks often result in the tragic deaths of women, children, and the elderly, along with widespread kidnappings and rapes. These assaults also lead to significant destruction of homes and medical facilities [15]. Displaced by these attacks, many people are forced into hostile environments with inadequate shelter, poor access to water, sanitation, and hygiene (WASH), and insufficient healthcare, facilitating the spread of diseases like cholera, typhoid, and schistosomiasis [11]. Vaccination is key to preventing infections. The output of armed conflict serves as one of the key barriers to preventing and eradicating vaccinepreventable diseases such as polio, pertussis, and measles. Insecurity concerns related to armed conflict affect vaccination energies in northern Nigeria, thwarting many children from receiving and/or impacting the immunization cycle [12]. For example, between 2019 and 2021, routine immunization in children decreased from 7.7% to 3.4% in Anka [15]. Likewise, in 2013, half of Nigeria's polio cases came from Boko Haramaffected regions, and the only polio case in 2014 came from Borno State. This is the result of inaccessibility to those who relocated to the uncomfortable area after an insurgent onslaught lowered the area's immunity compared to other comfortable locations, making a sizable number of children vulnerable to diseases [12].

Roles of governments and non-government organizations in tackling cholera in the regions
Non-governmental organizations (NGOs) have existed in developing countries for more than four decades and have played vital roles in managing the spread of communicable diseases [3,28]. The central area of concern for many NGOs involves improving healthcare systems and good governance Furthermore, one of the salient factors responsible for reemergence of cholera infection in most hotspot areas is poor/inadequate drinking water supply. A recent study has indicated that more than 60 million Nigerians do not have access to quality water supply, which has been shown to have a direct relationship with increasing cholera incidence in the country [30]. Most recently, an epidemiological survey showed that out of the six geopolitical zones in Nigeria, the Northeast and Northwest have higher fatality rates [31], requiring urgent government and NGO intervention. To end cholera's aetiology, the Nigerian government paid much attention to providing a safe drinking water supply and sensitization on personal hygiene and sanitation practices [32]. In 2019, Nigeria partnered with a United Nation agency, the International Organization for Migration, which supplied over 68 boreholes across Borno State as preventive measures against the cholera outbreak [33].
The role of NGOs in tackling cholera cannot be overemphasized.
They provide essential information to the government on the incidence of many infectious diseases in Nigeria. For example, during the 2015 cholera outbreak in two Internally Displaced Persons (IDP) camps in the Northeastern region, they (NGOs) immediately notified the Borno State government of the incidence of 30 suspected diarrhoea cases and seven deaths, which led to the recruitment of 6 Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) residents to investigate the matter properly In the Northwest, Kano is considered one of the most endemic regions with cholera cases resurfacing annually. Due to this, successive Federal and state governments have continued to provide good quality water supply and intervene in public health hygiene and sanitation to end the disease. Despite NGOs' and governments' involvement in tackling the cholera outbreak in the Northwest, the hotspot areas in Kano State were not fully identified [37]. In line with WHO directives to identify small hotspot areas ravaged by cholera, Nigeria established the "National Strategic Plan of Action on Cholera Control (NSPCC)" to identify and administer the vaccine in such affected areas [37]. This has led to the successful vaccination of about 710,212 people in Bauchi State. To sustain the fight against cholera, the "National Cholera Emergency Operations Center (EOC)" was reinvigorated in 2021, leading to massive support by the rapid response teams in the hotspot areas in the Northwest (Kaduna and Kano), Northeast (Bauchi) and Northcentral (Plateau and Benue) regions. In Borno State, the EOC improved the coordination, management and distribution of oral cholera vaccine in IDP camps and monitored Cholera incidence daily [37]. Other organizations that helped with the cholera containment in Northern Nigeria include Gavi, The Vaccine Alliance, United Nations Children's Fund (UNICEF), and WHO [32,38]. UNICEF not only aided some Northwestern and Northeastern states (Bauchi, Borno, and Katsina) with IV fluids, oral rehydration salts, water purification tablets and other logistics in the fight against cholera, but also sponsored television and radio sensitization programs in those areas.

Challenges facing cholera eradication in Nigeria
The use of culture-based diagnostic techniques is constrained in many cholera-prone areas in northeastern Nigeria due to low or inappropriate laboratory capacity, unstable security circumstances, limitations on movement, lack of necessary resources, the high population in the camps and insufficient funding to the humanitarian response plans and WASH [6].
Culture-based diagnostic techniques are constrained in many cholera-prone areas due to low or inappropriate laboratory capacity. Issues with personnel management, a lack of skilled laboratory personnel, a shortage of laboratory supplies, difficulties with sample storage and transit, and unreliable reporting bring about this restriction. Access issues brought on by persistent insecurity in affected and vulnerable areas are influencing the response, movement of essential supplies and the inability to preposition supplies, lack of resources necessary to manage cholera and obtain delivery supplies promptly, which affects preparedness, mitigation and case management. It is impacting all pillars of the response and scale up plans, with some of the worst-affected locations, such as Damboa and Gwoza towns in Borno State, already reporting shortages of vital kits and medicines. Camps have a relatively high population density, which makes it challenging to control a cholera outbreak [3].
As of August 2021, the Humanitarian Response Plan's (HRP) funding for the health and water, hygiene, and sanitation (WASH) components remains insufficient. Only 17 per cent of the requirement for Health ($14 million received out of $83 million requirement) and 1 per cent funded for WASH ($612,000 received out of $92.7 million required) as of the end of August 2021. Due to these difficulties, outbreak identification and control measure execution are delayed, which raises morbidity and mortality. Additionally, this reduces the capacity for investigating outbreaks and monitoring Vibrio cholerae circulating strains, particularly the potential to detect the introduction of novel strains that would necessitate quick modifications in response (such as adapted antibiotics or vaccines).

Joint Armed Forces Campaign against
Banditry and Insurgencies: As a top priority, a united effort from the armed forces should be initiated to quell banditry and insurgencies. Until terrorist organizations are effectively dealt with, the impact of other relief programs will remain limited. Collaborating with organizations such as the WHO and MSF can bring additional resources and support to tackle the cholera outbreak. 10. Providing Medical Treatment: Ensuring the availability of medical resources and personnel to swiftly and effectively treat cholera cases is vital.

Implementing
Community-Based Surveillance Systems: Training locals to recognize cholera symptoms and report cases can enhance the detection and response to potential cholera outbreaks.

CONCLUSION
Cholera remains one of Nigeria's major public health problems, particularly in the conflict-hit northern regions. A lack of information due to very little humanitarian access, dangerous security circumstances, and limitations on movement remain the major challenges facing the eradication of cholera in the regions. Others include low or inappropriate laboratory capacity, shortage of laboratory supplies, difficulties with sample storage and transit, unreliable reporting, and a general lack of financial assistance. These factors, together, have provided a breeding ground for cholera in the regions. It is, therefore, necessary to increase access to clean water by constructing a deep aquifer borehole and monitoring the water's quality. Prioritizing a joint campaign against banditry and insurgencies is crucial, as is ensuring the safety of aid workers and healthcare facilities. Establishing safe passages for aid, coordinating with local leaders, and improving sanitation and water access are also key measures. Increased access to cholera vaccines, public health education, international collaboration, and community surveillance systems, along with readily available medical treatment, round out a comprehensive approach to managing and eventually eradicating the cholera outbreak. Also, the health sector's budget shortfalls must be quickly addressed to maintain and expand current responses. Importantly, to end problems associated with banditry in the Northwest and insurgency in the Northeast, a lasting solution to the uprisings must be implemented.

Ethics approval and consent to participate
Not applicable.