EPIDEMIC CHOLERA AMONG REFUGEES IN MALAWI, AFRICA - TREATMENT AND TRANSMISSION

Between 23 August and 15 December 1990 an epidemic of cholera affected Mozambican refugees in Malawi causing 1931 cases (attack rate = 2.4%) ; 86 % of patients had arrived in Malawi < 3 months before illness ons et. There were 68 deaths (case-fatality rate = 3.5 %); most deaths (63 %) occurred within 24 h of hospital admission which may have indicate d delayed presentation to health facilities and inadequate early rehyd ration. Mortality was higher in children < 4 years old and febrile dea ths may have been associated with prolonged TV use. Significant risk f actors for illness (P < 0.05) in two case-control studies included dri nking river water (odds ratio [OR] = 3.0); placing hands into stored h ousehold drinking water (OR = 6.0); and among those without adequate f irewood to reheat food, eating leftover cooked peas (OR = 8.0). Toxige nic V. cholerae O1, serotype Inaba, was isolated from patients and sto red household water. The rapidity with which newly arrived refugees be came infected precluded effective use of a cholera vaccine to prevent cases unless vaccination had occurred immediately upon camp arrival. I mproved access to treatment and care of paediatric patients, and incre ased use of oral rehydration therapy, could decrease mortality. Preven ting future cholera outbreaks in Africa will depend on interrupting bo th waterborne and foodborne transmission of this pathogen.