Cholera outbreak caused by drinking unprotected well water contaminated with faeces from an open storm water drainage: Kampala City, Uganda, January 2019

Abstract

Background: Kampala city slums, with one million dwellers living in poor sanitary conditions, frequently experience cholera outbreaks. On 6 January 2019, Rubaga Division notified the Uganda Ministry of Health of a suspected cholera outbreak in Sembule village. We investigated to identify the source and mode of transmission, and recommended evidence-based interventions. Methods: We defined a suspected case as onset of profuse, painless, acute watery diarrhoea in a Kampala City resident (≥ 2 years) from 28 December 2018 to 11 February 2019. A confirmed case was a suspected case with Vibrio cholerae identified from the patient’s stool specimen by culture. We found cases by record review and active community case-finding. We conducted a case–control study in Sembule village, the epi-center of this outbreak, to compare exposures between confirmed case-persons and asymptomatic controls, individually matched by age group. We overlaid rainfall data with the epidemic curve to identify temporal patterns between rain and illnesses. We conducted an environmental assessment, interviewed village local council members, and tested water samples from randomly-selected households and water sources using culture and PCR to identify V. cholerae. Results: We identified 50 suspected case-patients, with three deaths (case-fatality rate: 6.0%). Of 45 case-patients with stool samples tested, 22 were confirmed positive for V. cholerae O1, serotype Ogawa. All age groups were affected; persons aged 5–14 years had the highest attack rate (AR) (8.2/100,000). The epidemic curve showed several point-source outbreaks; cases repeatedly spiked immediately following rainfall. Sembule village had a token-operated water tap, which had broken down 1 month before the outbreak, forcing residents to obtain water from one of three wells (Wells A, B, C) or a public tap. Environmental assessment showed that residents emptied their feces into a drainage channel connected to Well C. Drinking water from Well C was associated with illness (ORM–H = 21, 95% CI 4.6–93). Drinking water from a public tap (ORM–H = 0.07, 95% CI 0.014–0.304) was protective. Water from a container in one of eight households sampled tested positive for V. cholerae; water from Well C had coliform counts ˃ 900/100 ml. Conclusions: Drinking contaminated water from an unprotected well was associated with this cholera outbreak. We recommended emergency chlorination of drinking water, fixing the broken token tap, and closure of Well C.