Dealing With Cholera Joints: What’s The Best Approach?

20140404-204219.jpg

20140404-204232.jpg

20140404-204248.jpg

20140404-204258.jpg

I stumbled upon them last weekend in, surprisingly of all places, Victoria Island one of the most “highbrowed” neighborhoods in Lagos. Rows upon rows of street food vendors with patrons hustling to get the attention of the food seller and jostling for a place to sit with their plates of indescribably cheap food. Welcome to what I would call “Cholera Alley” or “Cholera Cul de Sac”. Not the most enviable place to have your lunch except you are amongst the many Lagosians living below the poverty level of less than a dollar a day.

Popularly called Cholera Joints, they are familiar sights in this country, especially in urban centers. Preparing and selling food under the most unhygienic circumstances, these roadside food vendors have gained notoriety as public health menaces, perhaps the number one public health menace in our urban society. Sometimes late last year four persons died in Lagos, from what the Lagos State Ministry of Health confirmed to be cholera, after patronizing roadside food vendors like these.

I was told that the term “Cholera Joint” was coined on Nigerian University and Polytechnic campuses many years ago to describe those low life cafeterias with plank and plywood walls and pot-holed concrete floors situated on the fringes of campus society where food is sold cheap and usually patronized by those students who couldn’t afford the opulent restaurants located in the Student Union Building.

These dodgy canteens were aptly named cholera joints by students because except you are extremely lucky you stand the chance of bagging a dose of vibrio cholerae, the causative agent of cholera, in addition to the cheap meal you pay for. As it is “Cholera joints” are not limited to campuses, the entire society is dotted with them, encouraged and spurred on by the high poverty levels in the land and further enhancing the public health burden of food-borne illnesses.

The public health problem of street food vendors is not limited to Nigeria, it’s a phenomenon common to developing countries. The question is how should this problem be addressed here in Nigeria?

Should there be an outright clamp down on them? I don’t think this strategy will work for three simple reasons:
1. These vendors are so widespread that it is next to impossible to locate them all to implement any effective clamping down exercise, and because they are very mobile with few fixed assets it will be easy to avoid being detected.
2. Secondly clamping down outrightly may cause social upheaval no matter how minor it will be anyway. It can be viewed as the rich again taking it out on the poor, a regular sentiment in our classed Nigerian society because majority of the poor depend on street food as restaurants are beyond their reach.
3. Street food vending has significant economic relevance. It occupies a large portion of Nigeria’s informal business sector and may be too important to outrightly clamp down on for this reason.

Another option is to legislate and regulate their activities. This would have been an effective strategy if the appropriate government commitment especially at the state and local government levels is present and also if there is availability of resources to monitor compliance to regulations and legislations. The first is very questionable and the second is doubtful because of how widespread and ubiquitous these food sellers exist all over the urban areas.

A third option is to reach out to these street food vendors and engage them in awareness campaigns, teaching them basic food hygiene practices that will protect their patrons and themselves, helping them to understand the benefits of improved hygiene and sanitation and where possible providing basic infrastructure for them such as food warmers, brooms, napkins, soaps, etc. Now this approach will naturally be painstaking and requires patience and persistence. Each roadside food vendor needs to be convinced and convinced thoroughly of the need for change and there are hundreds of thousands of them dotting the landscape. But it can be done, resulting in a win-win situation for government, the food vendors themselves and their customers.

This third option can be effectively pursued by NGOs with adequate fundings and grants and this is part of the objectives of Food-Borne Illness Prevention Initiative to reduce the public health burden of food borne illness in the society.

Know Thine Enemy & Know Thyself

Know Thyself & Know Thine Enemy

Sun Tzu

In the fight against food-borne illness, *Sun Tzu’s quote “know thine enemy and know thyself” is a good dictum to follow.

Why? Because in numerous kitchens (commercial kitchens, domestic kitchens in homes, and even communal village open-space kitchens) across the length and breadth of this country, the bugs that cause food-borne illness have been doing a lot of damage to the health and well-being of the public, and places considerable burden on the public health in Nigeria. Aided by ignorance of the populace, these pathogens seem to be having a field day. To turn the tide of this fight, folks need to know these germs, know how they infect, know the foods they are commonly associated with, know how they affect human health, and know how they can be curbed.

I have tried to profile five important food borne illness causative bugs in Nigeria in simple layman’s language as part of increasing awareness of these bugs, how they operate, and how they can be checkmated.

1. Vibrio Cholerae – Count for count, this food borne & water-borne bug has done more damage to public health in Nigeria than any other food borne illness bug.

To understand this check out my posts of 7th December and 22nd December titled 2013 Cholera Outbreak and Chronicling Cholera’s Carnage Parts 1 & 2 respectively.

Vibrio cholerae, the bug that causes cholera, is transmitted by consuming contaminated water or food washed or prepared with contaminated water or food prepared by a person sick with cholera.

Once the bug gets into the intestine of its victims it multiplies rapidly and secretes cholera toxin, it’s the toxin that does the damage by causing the intestine to release plenty of fluid that leads to its trademark symptoms; a sudden onset of watery stools and diarrhea. If not quickly treated the victims loose a lot of fluid from the body and die from dehydration. The suddenness of the watery stools and diarrhea is the characteristic of vibrio cholerae.

Hand-washing practices, properly boiling water before use, cooking food thoroughly, proper environment sanitation, use of latrines and toilets instead of open defecating are all ways of countering this bug.

2. Salmonella Spp – Salmonella bacterium is another major cause of food borne illness in Nigeria. The bug is transmitted by eating contaminated foods especially food of animal origin  i.e meat, poultry, eggs, milk. However fresh produce and vegetables have also been implicated in salmonella outbreaks. The bug gets into the food chain from infected livestock and animals where the livestock has been fed with salmonella contaminated animal feed. Fresh produce are contaminated when they are irrigated with sewage water containing salmonella or fertilized with animal manure of infected animals.

Food implicated in salmonella food borne illness in Nigeria are eggs (cracked eggs & eggs smeared with feaces), edible snails, roasted chicken sold by roadside vendors, improperly cooked chicken, local soft cheese “wara”, unpasteurized (raw) milk sold as fura-de-nunu, local sandwich and local salad. The salmonella bug was isolated in fillings from sandwiches that caused an outbreak of food borne illness in Ibadan that claimed about 20 lives some years ago.

In healthy adults the bugs needs to be consumed in large numbers to cause illness, but in the young and elderly a small dose is enough to cause trouble. Even though majority of the ingested bug gets destroyed in the stomach by gastric acid, the ones that survive and pass into the intestine and multiplies there resulting in the symptoms of diarrhea, fever, nausea, vomiting and stomach cramps usually between 12 – 72 hours after ingesting the bug. The illness may last 4-7 days. Serious forms of the illness can lead to fatality when the bugs spread from the intestines to the blood stream and then to other body organs especially in the young, elderly, or the sick.

Cooking food at temperatures at 75C for is sufficient to kill the bugs. Other means of preventing the bug from infecting is by avoiding cross contamination of the bug from raw food to other food i.e. not using same utensils (chopping boards, knives, work surface) for raw foods and ready to eat foods without thoroughly washing with soap and hot water, separating raw foods from ready to eat food in storage in fridge, ensuring proper cleanliness in the kitchen, and thorough washing and sanitizing fresh produce before eating.

3. Listeria monocytogenes – A contaminant found in Nigerian foods like smoked fish, kilishi (sun-dried & partially roasted seasoned meat slices), kununzaki (fermented sorghum drink), wara (local soft cheese popular in South West Nigeria), and unpasteurized (raw) milk sold as fura-de-nunu, Listeria monocytogenes, the bug that causes Listeriosis also referred to as L.Mono, is an uncanny food borne illness bug. Uncanny in the sense that unlike most food borne illness causing bugs, L.Mono can survive and even grow at temperature as low as 0C such that it multiplies even when food is refrigerated.

Naturally existing in soil, water and vegetation from where it gets into the food chain, L.Mono can be destroyed in food by proper cooking and pasteurizing. It’s symptoms are diarrhea, vomiting, nausea, fever, and muscle aches which may begin to manifest as short as few hours to as long as 3 months after ingestion (for the very severe type). Where you see the normal symptoms of food borne illness accompanied with aches at the knees and elbows as well as stiff neck, it’s probably L.Mono at work.

Healthy adults are rarely affected by L.Mono, it’s aged/elderly persons, pregnant women, newborns, and adults with weakened immune systems that are the groups mostly at risk of this bug. And of this group pregnant women are the highest number of its victims where the bug passes from the intestine into the blood and becomes blood borne affecting the fetus resulting in miscarriage or stillbirth.

Infection by L.mono can be prevented by cooking food thoroughly to safe temperatures, by washing and proper handling of food before eating, keeping kitchen environment clean, proper handwashing, separating raw food from ready to eat food, avoiding cross contamination, and avoid eating the high risks foods as listed above.

4. Staphylococcus aureus – This bug by itself is harmless and occurs naturally on skin, hair as well as nose and throats of humans and animals. However when it gets into food it rapidly multiplies and secretes very potent toxins into the food. The major source of contamination is from food handlers and food preparers.

Once it has multiplied and produced the toxins into the food, heating treatment or cooking of the food makes no difference anymore because the toxins are very heat stable and are not easily destroyed by heat. So cooking food that has been colonized by staph aureus may destroy the bugs themselves but the toxins survive and when the food is eaten the toxins cause the illness with symptoms of vomiting, diarrhea, nausea and stomach pains typically one to six hours after ingestion of the toxin and this may last between 24 – 48 hours before it subsides.

Staph aereus need time to multiply in food to the dangerous levels that are sufficient to cause illness. Leaving food unrefrigerated for a short period gives it the chance to do this.

Moi-Moi (bean pudding), Agidi (Fermented Corn Meal), Abacha (African Salad), Suya (Roasted Meat) and similar hand prepared meals are examples of Nigerian foods implicated in staph food borne illness.

Ways to prevent staph infection are avoiding time and temperature abuse of food, proper handwashing before food preparation, not allowing food handlers (and children’s nannies & caregivers) with open sores/boils/wounds/long fingernails/skin infections/nose & eye infection to prepare food, avoid coughing and sneezing unto food, eating food immediately after preparation, rapid chilling and cold storage of food to prevent multiplication of the bug in food.

5. Aspergillus flavus – Aspergillus flavus, unlike the previous four bugs above, is not a bacteria but a fungus found in food like maize, groundnuts, sorghum, groundnuts that produce poisonous toxin. This toxin can be very dangerous when ingested and cause aflatoxicosis. It has been reported to causes liver cancer, suppresses the immune system, and retards the growth and development of children.

Even though the toxin is invisible to the naked eye, the bugs can be discerned in crops by a characteristic mould green color.

Prevention of aflatoxicosis begins at the farm by treating the crops to kill the bugs and also during storage. Infected crops are usually destroyed to prevent human consumption. However some of these infected crops inevitably enters the food chain as Agidi, the peanut paste used to prepare Kilishi, Kuli-Kuli (local snack made from fermented groundnut), Yaji (the spice that accompanies Suya) and when livestock eat feed contaminated with Aspergillus flavus.

The toxins produced by the Aspergillus bug are not affected by routine cooking temperatures, but simple food preparation methods such as sorting, washing, crushing, and dehulling may reduce aflatoxin levels (Public Health Strategies for Preventing Aflatoxin Exposure 2005).

These five food borne illness pathogens, along with other such pathogens not profiled in this post, have collectively brought a huge burden on the public health system of this country.

*Sun Tzu was a Chinese general, military strategist, and author of The Art of War, an immensely influential ancient Chinese book on military strategy. (Source: http://www.wikiquote.org)