The Devils We Know


This post was contributed by Iruka N. Okeke – a Professor of Molecular Microbiology, Haverford College in the USA. Her book, Divining without seeds; the case for strengthening laboratory medicine in Africa, is a must read for anyone really interested in the field of infectious diseases. As we begin to pat ourselves on the back for the response to the Ebola outbreak in Nigeria, Iruka raises an important issue here that will lead you to think … then think again.

Nigeria deserves more than a pat on the back for managing to quell an Ebola outbreak that began from an imported index case. The Ebola saga and the watchfulness needed to contain it are not over yet. As long as the virus continues to rage elsewhere, we must remain vigilant to ensure that it does not spread within our borders. Ebola represents a particularly challenging case. Until recently, its endemic focus was in central Africa but is now much closer to Nigeria, there is no approved vaccine, and there are no certified cures. There are however tried and true mechanisms to contain an outbreak once it has begun, and it is these methods that Nigerian officials, health workers and volunteers have applied in the current outbreak.

Cholera Vaccines (Photo: Michael Tsegaye / MSF)

Prior to the arrival of Ebola, Nigeria and some other West African countries began a struggle to contain cholera, a deadly epidemic disease that can cause gruesome death from dehydration within hours. Cholera is caused by certain strains of the bacterial species Vibrio cholerae. Two centuries ago, the arrival of the curved bacterium in any locality occasioned the same response from within and abroad that the threadlike Ebola virus does today. We now know that cholera is spread when susceptible people drink or eat material contaminated with faeces of the infected. We also know that, if people who get cholera are rehydrated early and appropriately, they almost inevitably survive the disease, even without additional medications. Additionally, there are now vaccines that can prevent cholera. These are far from perfect vaccines, in some settings protecting only 70-80% of susceptibles from the infection. However, they offer herd protection, that is, if enough people are vaccinated, some unvaccinated people are protected. In vaccinated populations, cholera infections can be less severe and less transmissible, and treatment resources only need to be targeted to a few people. Moreover, in contrast to earlier injected vaccines, today’s cholera vaccines can be administered orally. It is these features of cholera vaccines that have prompted cholera researchers, epidemiologists and health-policy makers to advocate for an international cholera vaccine stockpile, to which health ministries can apply for vaccines at short notice. Vaccines should be applied to populations that have lost their water supplies due to natural disasters and are therefore vulnerable to cholera. They should also be given to refugees and Internally Displaced Persons (IDPs). The current West Africa epidemics, a focus of these epidemics in northern Nigeria and populations fleeing Boko Haram in the same parts of the country make cholera vaccination essential for Nigeria’s IDP camps.

Cholera Vaccines (Photo: Michael Tsegaye / MSF)


An oral cholera vaccine stockpile program is now active and managed by the World Health Organization. There have been multiple reports of cholera outbreaks occurring in Nigerian IDP camps. We need to ask ourselves why our people are dying of a disease that is preventable and curable when our country has the capacity to contain an incurable disease. Why are Nigerians that are fleeing Boko Haram and safe from Ebola succumbing to cholera? And why are their children also at risk of dying from vaccine preventable measles, which is covered by Nigeria’s immunization program? One person interviewed in a Taraba state IDP camp described his existence as ‘hell on earth‘. Let us protect our compatriots from the devils we know.

Iruka N Okeke

Department of Biology, Haverford College, PA USA

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