Choléra Epidémiologie et Réponse Factsheet MALI

CHOLERA EPIDEMIOLOGY AND RESPONSE FACTSHEET MALI

CHOLERA OVERVIEW

Cholera was first reported in Mali in 1970. Since 1990, there have been large outbreaks in 1995–1996, 2000, 2003–2005 and 2011 (Fig. 1).

Between 2003 and 2013, epidemiological surveillance reported 8,094 cases with 521 fatalities (high case fatality rate ≈ 6.4%)1.

Main outbreaks were reported in the region of Mopti, Tom-bouctou and Ségou along the Niger River and in the region of Kayes at the border with Senegal (Tab. I and Fig. 2).

The country is affected by cross-border outbreaks, especially along its southern borders with Niger, Burkina Faso, and towards the west with Mauritania and Senegal.

CHOLERA DISTRIBUTION

Between 2003 and 2013, over 70% of cases were reported in the neighboring regions of Tombouctou, Mopti and Ségou along the Niger River. The highest cumulative incidence was seen in Mopti, Tombouctou and Youwarou cercles (Fig. 2 and Tab. I).

In north east Mali, the Gao region reported 8% of cholera cases and the highest activity was seen at the border with Niger (Asongo) (Fig. 2 and Tab. I).

In south west Mali, the highest level of activity was registered in Nara cercle in Koulikoro region. At the border with Senegal and Mauritania, the region of Kayes reported 12.4% of the cholera cases, with Kayes and Diema cercles being the most affected. Very few cases were notified in the capital Bamako and the neighboring region of Sikasso (Fig. 2 and Tab. I).

There is no clear pattern of the onset time of outbreaks in Mali, as onsets occured during both the dry and the rainy seasons. However, there is an increase of the number of cases reported during the rainy season between June and October3,5.

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

Figure 2. Cumulative incidence of cholera by cercle in Mali, 2003–20132

RegionCases /

Deaths [1]

% of total cases

CFR (%)

Number of outbreaks

Mopti 2,243 / 138 32.6 6.2 3

Tombouctou 1707 / 99, 24.8 5.8 3

Ségou 918 / 87 13.3 9.5 3

Kayes 854 / 68 12.4 8 3

Gao 593 / 42 8.6 7.1 3

Koulikoro 506 / 34 7.3 6.7 3

Sikasso 50 / 4 0.7 8 2

Bamako 15 / 4 0.2 2.6 1

Table I. Epidemiological parameters of cholera outbreaks by main affected region in Mali, 2003–20132

Note : [1] Total of cases = 6,864 and deaths = 474 between 2003 and 2013.

Overall the country is often affected by cross-border outbreaks from Senegal (2005), Mauritania (2005) and Niger (2011 and 2012). Cholera outbreaks in Mali spread along the Niger River towards Niger (1996, 2004, and 2006).

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CHOLERA HOTSPOT IDENTIFICATION

Overall, cercles regularly affected and with a medium to high incidence are located (Tab. II):

• at commercial and religious cross-roads : Mopti, Djenne, Tombouctou, Ségou and Gao;

• along the River Niger: Asombo, Bourem, Youwarou, Tenekou, Djene, Macina, Dire, Goundam, Niafunke and Gourma Rharous;

• at the border with Senegal and Mauritania: Kayes, Nara and Djema.

High-risk cholera areas along the Niger River and at the border with Senegal and Maurita-nia are located on a corridor where outbreaks spread from and to neighbouring countries — Niger, Burkina Faso, Mauritania and Senegal — highlighting the importance of cross-border activities5 (Fig. 2, Tab. II).

In cercles regularly affected, preparedness and response plans should be developed and implemented including: (I) strengthening early detection and rapid response systems of which community based surveillance and cross-border alert; (II) setting up coordination mechanisms across the sectors and borders; (III) building capacity on outbreak management; (IV) targeted pre-positioning of supplies and (V) preparing communications messages and plans (Tab. II).

Sustainable Water, Sanitation and Hygiene activities (WASH) should be a priority in cercles regularly affected and with a high incidence (Tab. II, Priority 1). There is a need for multi-disci-plinary studies to identify long-term programma-tic responses in Priority 1 and Priority 2 Hotspots (Tab. II). Yet, information regarding onset area and outbreak duration should be looked at prior conducting a study. Only cercles with a long to medium outbreak duration (>40th quantile) should be eligible for WASH intervention.

References1. Global Health Atlas, WHO: http://apps.who.int/globalatlas.2. Ministry of health Mali, 2003–2013 cholera data.3. Cholera Country Profiles - Mali., WHO, 2013

(http://www.who.int/cholera/countries/en).4. Multiple Indicator Cluster Surveys (MICS) and Demographic and

Health Surveys (DHS), 2012: http://data.unicef.org/water-sanitation/sanitation.

5. Dao Sounkalo et al., Cholera outbreaks in Mali between 1995 and 2004, Santé Publique, 2009/3 Vol. 21, p.263–269.

6. Dao Sounkalo et al., Factors of propagation of 2003 cholera outbreak in Mali, Mali Médical, 2005/3.

AcknowledgementsDunoyer J. (coordination, UNICEF WCARO), Sudre B., MD PHD (scientific advice), Green HK., PHD (data analysis), Rossi M. (spatial data mana-gement).

Figure 3. Water and sanitation coverage estimates in Mali, 1990–20124

Table II. Summary of cholera hotspots classification and strategic interventions in Mali, 2003–20132

Note : Priority 1: High priority area with a high frequency (>80th percentile) and a high incidence (>60th percentile). Priority 2: Medium priority area with a moderate frequency (40th–60th percentile) and a high incidence (>60th percentile). Priority 3: Medium priority area with a moderate to high frequency (>40th percentile) and a moderate incidence (40th–60th percentile).

REGION CERCLE Cases / Deaths% of total

casesCFR (%) Recurrence

(No of outbreaks)Incidence

(per 10,000 inhab.)Cross-bor-der spread

Priority

GAO

ANSONGO 284 / 28 4 9,9 2 19 Yes 2

BOUREM 15 / 6 2 4,0 2 11 Yes 2

GAO 76 / 13 2 4,4 3 5 No 3

KAOUIKAOUI 723 / 56 11 7,7 3 12 No 1

DIEMA 131 / 12 2 9,2 2 5 No 3

KOULIKORO NARA 438 / 27 6 6,2 3 16 No 1

MOPTI

MOPTI 1,237 / 61 18 4,9 3 29 No 1

YOUWAROU 346 / 24 5 6,9 3 28 No 1

TENENKOU 327 / 30 5 9,2 3 17 Yes 1

DJENNE 243 / 13 4 5,3 3 10 Yes 3

SEGOUSEGOU 433 / 52 6 12,0 2 5 Yes 2

MACINA 200 / 11 3 5,5 2 7 No 3

TOMBOUCTOU

TOMBOUCTOU 413 / 23 6 5,6 3 29 Yes 1

DIRE 316 / 17 5 5,4 3 25 Yes 1

GOUNDAM 393 / 24 6 6,1 3 23 No 1

NIAFUNKE 400 / 22 6 5,5 3 19 Yes 1

GOURMA RHAROUS 185 / 13 3 7,0 2 15 No 2

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STRATEGIC RECOMMENDATIONS

Livelihood groups and high risk practices to be considered in prevention, preparedness and response strategies6:

• commercial and religious cross-roads in Mopti, Tombouctou and Gao regions;

• communities living by the River Niger including nomadic fishermen between Gao and Koulikoro;

• social activities such as home visits to the sick person’s family and

funeral rituals.