Factors associated with repeated cholera outbreaks: a case of Arua district, Uganda
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Introduction and Background: Cholera has remained a global health problem despite the advent of modern medicine and mainly affects developing countries where the public health community is least prepared to handle outbreaks. In some parts of Arua district, cholera outbreaks have occurred annually since 1998. General Objective: To assess factors associated with repeated cholera outbreaks in Arua district to generate information that may be used by the district health team/stakeholders to implement interventions to prevent further outbreaks. Methods: This was a cross-sectional comparative study employing qualitative and quantitative methods of data collection, conducted in Arua district, comparing communtites that had two or more cholera outbreaks to communities that had one or no cholera outbreaks between 2002-2005. The study population were communities where the study was conducted. Multistage cluster sampling was used to calculate sample size, 26 clusters were selected per arm and eight respondents were interviewed per cluster. Semi-structured questionnaires and observational checklists were used to collect qualitative data and key informant guides and focus group discussion guides used to collect qualitative data. Quantitative data was analyzed using EPI-Info 2002, SPSS 11.5 and Ms Excel computer soft wares and qualitative data was analyzed using the master sheet. Results: Factors associated with repaeated cholera outbreaks that were identified at bivariate analysis included: Low level of education, living in a congested household, not having knowledge about cholera, lack of a pit latrine in homes, getting water for domestic use from unprotected water points, drinking untreated water, not washing hands before handling and eating foods and eating cold foods from vendors. After adjusting for confounders using logisitic regression, factors associated with repeated cholera outbreaks were, drinking untreated water (OR= 6.72, 95%ci: 2.457-18.38), not washing hands with water and soap before eating food (OR 16.27, 95% CI 3.63-72.83), eating unheated leftover foods (OR =3.78, 95% CI: 1.76-8.12), and being a peasant/trader (OR = 2.53, 95% CI:1.01-6.31), presence of a pit latrine was protected (OR=0.04, 95%CI: 0.01-0.12). Other important factors were; lack of a budget for outbreaks, rapid response team meeting only when there are outbreaks, and an inadequate surveillance system. Conclusion: Key factors observed in communities that had repeated cholera outbreaks were, Low level of knowledge about cholera, inadequate safe water coverage, poor personal and domestic hygiene and inadequate capacity in the district to handle cholera outbreaks. Recommendations: The DDHS and the other stakeholders should therefore strengthen health education; work in collaboration with rural water and sanitation departments, works and housing as well as the education departments to reduce the potential risk factors in these areas.