Global Health Problem – Cholera

Low and middle-income countries continue to be affected by infectious diseases.  One such disease is cholera which has remained a global health problem. It is important to note that the proportion of people suffering from the effects of Cholera-related incidents is highest in Africa than elsewhere in the world.  According to the World Health Organization (WHO), the simultaneous progression of cholera outbreaks in Africa is facilitated by a wide range of factors such as fragile health care systems and humanitarian crises, overstretched medical personnel, lack of public health services, decreased to no resources, and inadequate cholera vaccines. (Saez et al., 2022). This has facilitated that infectious disease and acute diarrheal illness have remained one of the tenets of focus of the WHO, especially when developing sustainable developmental goals. 

NURS FPX 8014 Assessment 2 Global Issue Problem Description

Cholera has been perceived as an easily treatable illness; most Cholera endemic countries have a direct link with the transmission of Cholera and inadequate access to clean sanitation facilities and water. (Lessler et al., 2018).  Research has shown that in urban areas, an increased risk in camps and peri-urban slums for refugees or internally displaced persons are found to experience outbreaks due to subminimum sanitation and lack of safe drinking water. The international health community has been dramatically affected by the presence, containment, and eradication of the acute diarrheal disease, Cholera.  While focusing on African countries, recent studies have indicated Uganda as one of the countries prone to cholera outbreaks. 

Since the first cholera outbreak in Africa was reported in 1971, the Global Task Force on Cholera Control(2017) affirms that Uganda has continued to experience cholera outbreaks annually. The ongoing burden of cholera in rural and urban areas has been of much concern. It is a known and acceptable treatment for the disease. However, efforts to eradicate and cease ongoing outbreaks have failed. 

Cholera is a highly transmittable diarrheal disease caused by the bacterium Vibrio Cholera. (Debes et al., 2021).  The common link for the disease is the relationship between water and disease transmission. (Debes et al.,2021).  Cholera can be acquired when the sources of drinking water have been contaminated. (Debes et al., 2021).  Cholera can cause severe watery diarrhea and vomiting, and epidemics of the disease have been closely linked to extreme crises in populations or communities, such as disasters, loss of community infrastructure, floods, earthquakes, and civil unrest, which leads to the breakdown of community services. (Debes et al., 2021).  

This paper aims to introduce the global health concern of Cholera and its effects on the worldwide population. It will review and evaluate the description of the problem what are the critical components of the social and environmental determinants that impact the situation. During evaluation and assessment, strategies and gaps in services will be identified. The aim is also to propose culturally sensitive and community-focused interventions that will empower the population affected, specifically in the chosen country of assessment. 

Description of the Problem

As an international health issue, it is essential to note that cholera outbreaks have been associated with limited access to clean water and poor sanitation.  The World Health Organization reports an estimated 2.9 million cases of cholera and 95,000 deaths related to cholera worldwide. (WHO, 2022).  The data on cholera is incomplete, as underreporting is common in many low-income countries. Cholera has been associated with and indicated as one of the identifiable indicators of the wealth of a population and has been designated as a sign of poverty. 

As stated, due to poor reporting of the disease event, the estimates may not reflect the true extent of cholera as an international and global health concern. Research has shown that cholera outbreaks have become prevalent in developing countries, especially Haiti, South Asia, and sub-Saharan Africa. (Saez et al., 2022). It has been found that the scope of the cholera problem differs from region to region over time. (Saez et al., 2022).  Notably, the mortality rate for outbreaks varies depending on the outbreak’s severity and treatment availability. 

Risk factors such as crowded living conditions, inadequate access to clean water, and poor sanitation increase the chances of contracting cholera. (Panda et al., 2020).  The efforts to control and prevent the spread of cholera from one region to the other are significant in the severity of the disease. (Panda et al., 2020).  Whereas the WHO, in collaboration with other international organizations, has worked relentlessly to address the global health burden associated with cholera, the simultaneous progression of cholera outbreaks in parts of Asia and Africa is wanting. 

Uganda is an east African country that borders Sudan in the north, the Democratic Republic of Congo in the west, Kenya in the east, and Rwanda and Tanzania in the south. Notably, these countries, except Rwanda, have had episodes of cholera outbreaks in recent years, which also increases the risk of the epidemic crossing the boundaries to Uganda, thus increasing the risk of cholera outbreaks in Uganda. Uganda, which lies in the Nile basin, has had many incidents of the cholera epidemic, often in rural and highly populated urban areas like Kampala. (Bwire et al., 2018).  

Research on the African Great Lakes basin has shown that the lakes are reservoirs of toxigenic Vibrio cholerae 01 and 0139 bacteria, in which pathogenic bacteria from neighboring communities contribute to the infestation. (Bwire et al., 2018). The discovery prompted the premise that cholera is endemic to Uganda and that outbreaks were especially prominent in the African Great Lakes in Uganda, the River Nile, and the international country borders. (Bwire et al., 2018).  The other premise that became evident is the introduction of the pathogen into communities by human visitors, traders, families, and refugees of neighboring endemic countries. (Bwire et al., 2018).  

Another risk factor associated with the prevalence of cholera in Uganda is the seasonal variation of the rainy seasons of Uganda. (Bwire et al., 2018).  Uganda has two rainy seasons, March through June and September through November, and it has been found that during these climatic changes, there is an increase detection of V.cholarea 01 and 0139, which has been associated with the endemic nature of the disease, as water sampling detected higher levels on the specimens tested. (Bwire et al., 2018).  

Amidst the COVID-19 pandemic, it is essential to note that several African countries, including Uganda, have faced confirmed cholera cases.  In Uganda, a cholera outbreak was reported in the Moroto district on May 14th, 2020. (Saez et al., 2022).  The cholera incident in Northeastern Uganda permeated when the nation was under lockdown following the immense spread of the COVID-19 virus. (Belay et al., 2022).  During that time, the Moroto district, like other Ugandan districts, was increasingly preoccupied with observing COVID safety precautions such as mask-wearing, handwashing, curfew, social distancing, and movement restriction.  Unfortunately, the district failed to oversee an impending outbreak that claimed the lives of thousands. (Panda et al., 2020).  It was affirmed that during the COVID-19 era, neighboring countries such as Sudan and Ethiopia also recorded cholera outbreaks. (Panda et al., 2022).  This alone reflects the significant challenge in African countries paralyzed by a cholera outbreak.  Furthermore, evidence indicates that the Moroto district has an ongoing challenge in accessing clean water sources. (Deoshatwar et al., 2022).  For instance, 70 % of the residents in the district have to walk more than 30 minutes to access clean sanitation and water. (Debes et al., 2021).  Following the increased limitation of humanitarian services in the district, there is a great hindrance to campaigns against the worsening burden of a cholera epidemic. (Debes et al., 2021).  

Social Determinants that Impact the Problem

One of the most significant factors attributed to the health of communities is grounded in the principles of the social determinants of health and how these factors can determine the health status of communities.  These economic and social conditions influence individual, community, and population health. (Munezero & Manoukian, 2021).  According to the World Health Organization, social determinants of health are more important than healthcare or other choices, such s lifestyle influencing health and health behaviors. WHO, 2022).  The WHO has divided the social determinants into five interdependent domains that can affect health and health-seeking behaviors.  (WHO, 2022).  The WHO further divided the social determinants of health into two perspectives: structural determinants and intermediate determinants. Structural determents include socio-economic, political governance, economic policies, and social and cultural values. (WHO, 2022).  Intermediate determinants are material determinants and psychosocial and behavioral characteristics such as living and working conditions of people such as work, housing, and medical care. (WHO, 2022).     

A wide range of socioeconomic influences is associated with cholera outbreaks in lower-economic developing countries. The number one social determinant is where we live. (Munero & Manoukian, 2021).  One of the critical factors shown through historical discoveries of cholera is poor sanitation and contaminated water sources.  Cholera is an acute diarrheal infection caused by ingesting contaminated food or water with the bacterium Vibrio cholerae. (Saez et al.,2022).  The lack of access to clean water, open defecation, and inadequate sewage systems plays an essential role in the spread of cholera. (Belay et al., 2022).  Uganda has a significant sanitation problem, particularly in urban slum areas and rural areas. (Belay et al., 2022).  The more substantial problem lies in the contamination of water sources, whereby most communities have inadequate waste management and sewage disposal systems. (Belay et al., 2022). Most inhabitants of Uganda rely on water sources from wells, lakes, and rivers; there is a high likelihood that water is contaminated with cholera bacteria. Uganda has not met the SDG standards for water and sanitation, and infract has a zero point eight six rating when applied to attaining SDGs established by the United Nations members. 

In addition to the probability of contaminated water sources, open defecation remains a significant problem in Ugandan communities. (Saez et al., 2022). The lack of adequate sanitation and toilet facilities has contributed to the spread of cholera. Studies conducted by the Global Task Force on Cholera Control found that less than twenty-eight percent of the population residing in rural Ugandan communities have access to basic sanitation. (Gapminder, 2021).   Unfortunately, the lack of adequate resources to support sanitation programs and limited investment in sanitation infrastructure in rural areas is problematic. 

Another social determinant that can contribute to cholera outbreaks is poverty. (WHO 2022).   Poor communities are more vulnerable to cholera outbreaks following a lack of proper sanitation infrastructure and clean water. (Panda et al., 2020).  In addition, poverty significantly impacts access to healthcare, making treating and diagnosing cholera cases more challenging.  As a result, inadequate essential health services often exacerbate the spread of cholera, contributing to higher mortality rates in poor communities. This scenario is evident in Uganda, where ninety percent of the population lives on one dollar and ninety cents per day. (Gapminder, 2022).  Furthermore, poverty is widespread in Ugandan urban slums and rural areas. (Saez et al., 2022).   A 2020 World Bank report classified Uganda as one of the poorest countors globally, with a poverty rate of a little over Tweety-one percent of the entire population. (Saez et al., 2022).   The Ministry of Health in Uganda recognizes that poverty significantly contributes to cholera outbreaks in urban slums and underdeveloped rural areas. Hence, any effort to eradicate the cholera outbreak in Uganda should focus on improving access to essential services, including healthcare, sanitation, and clean water. Furthermore, the Ugandan government should consider investing more in affordable healthcare services, healthcare education programs, and sanitation infrastructure for impoverished people. 

Political Influences

Many political factors influence the government’s response to a cholera outbreak.  Factors include the overall political climate of the Country, willingness to allocate resources to respond to epidemics, and the availability of resources. (Saez et al., 2022).  In most cases, the biggest challenge is the overall slow response to outbreaks due to inadequate resources. (Saez et al., 2022).  There are also instances when political factors such as political instability or corruption make it impossible to address cholera outbreaks effectively. (Ramamurthy et al., 2019).  The Ugandan government has experienced many challenges in response to cholera outbreaks.  One particular problem is the weak health system.  It has been found that there continues to be limited access to treatment and diagnostic services, few healthcare workers, and poor infrastructure, all compound the challenges of unmet needs in terms of cholera. (Deoshatwar et al., 2022).  Poor coordination of services is another barrier to poor response to cholera outbreaks. (Lessler et al., 2018).  The coordination between various government agencies, local government agencies, the Ministry of Water and Environment, and the Ministry of Health remains ineffective. (Deoshatwar et al., 2022).  These challenges have made adopting a multifaceted and well-coordinated approach complex, evidenced by effective responses to cholera outbreaks. 

Stigma and discrimination

During cholera outbreaks, communities and individuals affected by the disease face discrimination and stigma.  It has been found that political factors, religious factors, and ethnic divisions can influence the stigma and discrimination of people and communities.  (Belay et al., 2022).  Therefore, political leaders play an essential role in addressing the discrimination and stigma these communities feel and have to play a vital role in promoting inclusive policies and voicing concerns about such behaviors. (Panda et al., 2020).  In addition, leaders can shape the public perception of the government towards responding to cholera outbreaks. (Panda et al., 2020).  Therefore, government officials must demonstrate competency in addressing the political pressures of o cholera outbreak. (Panda et al., 2020). 

Like most African countries, it is noteworthy that Uganda’s vulnerable population is not exempt from the stigma and discrimination endured during cholera outbreaks.  For example, during the 2018 cholera outbreak, it was shown that the Muslim population in the Busoga sub-region was discriminated against and blamed for spreading cholera.  The idea arose from the Islamic practice of communal washing as a part of prayer rituals and was implicated in the spread of cholera in that region.  This further exacerbation the concern, for the little information and knowledge about the spread of cholera was exaggerated in this instance.  Though ill-advised in the presence of cholera and as a part of prevention practices, communal bathing should have been a teaching point to be emphasized by healthcare workers or community workers.  As the direct cause of the cholera outbreak was not sufficiently traced, misinformation dominated the event, deterring the prevention efforts in general.  

NURS FPX 8014 Assessment 2 Global Issue Problem Description

Another political influence affecting cholera outbreaks is international aid.  Over the years, the Global Task Force on Cholera Control (2017) has ascertained that cholera outbreaks successfully attract attention and international assistance, even in politically unstable, vulnerable countries.   Factors such as geopolitical considerations and relationships with donors impact international aid.  It is worth noting that there are instances where political leaders have rejected international assistance due to political concerns or, conversely, leveraged international assistance to broader political goals not related to the intended need or use of the resources. (Saez et al., 2022).  While looking at Uganda, it has been ascertained that this country has relied on sanitation facilities, water treatment equipment, medical supplies, materials, and technical assistance from international organizations such as the United Nations International Children’s Fund (UNICEF) and the WHO to respond to cholera outbreaks. (Saez et al., 2022).  The only limitation is the lack of coordination in international aid efforts to benefit vulnerable populations and communities. (Belay et al., 2022).  There needs to be a concerted effort to facilitate a targeted and responsive approach to respond to endemic cholera areas. (Belay et al., 2022).  

Uganda has one of the weakest political stability index ratings in the region.  Regarding political stability, judgment is made when querying data about corruption in politics, international transparency perception, political rights, civil liberties, and competitiveness.  According to the World Bank, Uganda’s political index has been rated at negative two points five, with the current rate being negative zero point eight six. These factors contribute to the ability or inability to garner international aid and assistance.  In addition, the negative connotations of the country’s impact on humanitarian and infrastructure, the increased potential for funding diversion, and their political leaders’ trustworthiness make investors hesitate to render assistance. (Belay et al., 2022).    

Cultural influences

Cultural beliefs and practices can significantly impact cholera transmission and spread.  According to recent investigations, governments and policymakers can only design effective control and prevention strategies by acknowledging existing cultural beliefs and practices. (Deoshatwar et al., 2022).  Many cultural beliefs are attributed to this population, such as using communal water sources, which can impact cholera prevention and control. (Debes et al., 2021).  People relying on communal water sources are more likely to transmit cholera, mainly if it has been found that the actual water sources have already been contaminated with waterborne and cholera pathogens. (Debes et al., 2021).  

In Uganda, water sources are increasingly communal in different parts of the country and have been especially practiced in rural and urban areas. Uganda’s total population is forty-five point eighty-five million people reside in Uganda. (Gapminder, 2021).  Seventy-Six percent of the residents live in rural areas. (Gapminder, 2021).  It has been postulated that a bare eight percent of those living in rural areas have access to safe drinking water. (WHO, 2020).  Uganda’s population age groups can be further delineated with the following age groups two and zero-one percent of the population is age sixty-five or older, and age zero to fourteen comprise forty-five and sixty-eight percent of the people in 2021.  Uganda has been found to have one of the youngest populations in the world.  Twenty-five point fifty-five percent of the population live in urban areas.  

Additionally, traditional and religious beliefs can influence cholera transmission. (Belay et al., 2022).  It has been found that the communities and people of Uganda are more likely to turn to traditional healers for illness and sickness. This further delays the much-needed services for intervention into a particularly virulent disease.  It further delayed access to health care services and failure to seek proper medical treatment and diagnosis of cholera. Overall cultural influence is a sensitive subject that demands the engagement of traditional healers, religious leaders, healthcare providers, and community leaders to encourage early detection and treatment of cholera and to promote beneficial hygiene practices. (Saez et al., 2022). 

It is estimated that forty-two point seventy percent of the population live in poverty, with a cost of living index of forty-eight point forty-seven percent. (Gapminder, 2021).  Seventy-three percent of the workforce is employed in agriculture. (Gapminder, 2021).  At the same time, forty-one percent of the population has been found to exist on one dollar and ninety cents per day—less than fifty-three percent of the children in Uganda complete primary education. The life expectancy in Uganda is sixty-two point eighty-five years. (Gapminder, 2021).   The female and male population is almost equal, and no clear distinction noted differences in the number of males versus females.  It is of note that Uganda hosts the largest refugee population in the region; over one point five million refugees are residing in Uganda. (Gapmnider, 2021).  

Strategies and Gaps

Throughout the years, cholera has remained a global health issue that has yielded a variety of strategies and research. Cholera has been around for hundreds of years. It became a well-known disease after a massive outbreak in India. (Deoshatwar et al., 2022).  There have been many outbreaks and seven global pandemics. (Deoshatwar et al., 2022).  Cholera infects one million three hundred thousand to four million people worldwide, with death toll estimates of twenty-one thousand to one hundred and forty-three thousand deaths. (WHO, 2022). Cholera is caused by the bacterium Vibrio Cholerae, which typically lives in salty and warm waters such as estuaries and waters along coastal areas.  Cholera is contracted after consuming contaminated foods and water. (Deoshatwar et al., 2022).  Numerous strains of cholerae, serogroups O1 and O139, have been linked to outbreaks and epidemics. (Deoshatwar et al., 2022).  These serogroups produce cholera toxins that induce the intestinal lining to release increased fluids contributing to diarrhea, rapid fluid loss, and electrolyte depletion. (Deoshatwar et al., 2022).  

One of the earliest strategies to address cholera was to quarantine the population. (Panda et al., 2020).  Early in the nineteenth centers, quarantine was a strict measure utilized to prevent the spread of the disease. (Panda et al., 2020).  Notably, individuals who, on clinical presentation, were diagnosed with cholera were isolated from the rest of the population and restricted from travel. (Panda et al., 2020).  Unfortunately, this measure was ineffective, and cholera continued to cause death and infirmity.

Cholera has existed since what is thought to be at least 500 BC. (Ramamurthy et al., 2019).  The earliest discovery of the bacteria was in 1854 by an Italian, Filippo Pacini. In the mid-1800, London anesthesiologist John Snow conducted field investigations on the disease. (Ramamurthy et al., 2019).  His studies on cholera outbreaks, discovering the cause of the disease and preventing its recurrence. His findings heralded the practice of “mapping” the area where people lived and worked and the relationship to cholera. (Ramamurthy et al., 2019).  He also postulated water was the source of cholera. After mapping where community water pumps were located, he linked the use of the pumps with cholera outbreaks.  His simple therapeutic intervention was to shut the water pumps in the affected areas off. (Ramamurthy et al., 2019).    

Cholera treatment and interventions continued to be innovated. 1885 the first cholera vaccine emerged, where live bacteria was inoculated into affected populations.  Dr. Ferran, under the tutelage of Louis Pasteur. The mass vaccination of fifty thousand people during the Spanish outbreak was found to be effective.  The vaccination principle was improved by scientists Sawtschenko and Sabolotny used killed bacteria as the basis of their vaccine-like broth. Though effective, it was deemed impractical as it required multiple doses to be effective. (Sack, 2014 ).  Cholera vaccine research continues to be ongoing at this time.  

Another historical treatment was injecting water into the veins of people suffering from cholera. (Sack, 2013).  Using water to replace fluids lost from cholera infection heralded the addition f salts to the water injection to decrease fluid loss from acute diarrhea. (Sack, 2013).  Other conventional treatments consisted of enemas, castor oil, calomel mercurous chloride, gastric washings, venesection, opium, brandy, and plugging of the anus to prevent fluid loss. (Sack, 2013).  The primitive therapies led to using oral replacement therapies, with higher concentrations of salts, by Sir Leonard Rogers at Calcutta Medical College.  (Sack, 2013). This method was found to decrease the mortality rates from sixty percent to thirty percent. (Sack, 2013).  Further improvements in oral therapy with sodium bicarbonate and sodium chloride decreased mortality by an additional twenty percent. (Sack, 2013). 

The final and ongoing advances in cholera treatment involve advances in oral vaccine use.  The oral vaccine evolved from killed whole cells of the cholera bacteria in 1970 to modern-day therapy. (Sack, 2013).  Current oral vaccines involve binding the V.Cholerae serogroup with a non-toxic cholerae toxin to stimulate the immune response. (Sack, 2013).  Unfortunately, there is a current oral cholera vaccine shortage. The Global Task Force on Cholera, under the direction of the WHO and the international committees, has suspended the recommended two-dose administration of the oral vaccine to one dose. As a result, the sustainability of effectiveness and protection is in question. This is a potential contributor to the inability to decrease cholera outbreaks in endemic areas. 

Over the years, cholera remained a global health issue and has yielded a variety of strategies and research.  To begin with, the cause, prevention, and treatment of cholera became a prime focus globally as the disease continued to penetrate and affect large numbers of the population.  With the ongoing research, sanitation, hygiene, vaccines, and treatment became the hallmarks of treatment, prevention, and monitoring.  Surveillance of affected areas and populations served as measures utilized to clamp down on the fast spread of the disease.  

In the mid-twentieth century, the burden of cholera has remained a dominant public health issue in many developing countries.  Problems with inadequate access to clean water, poor sanitation, and underdeveloped waste disposal systems remain a focus of international organizations as cholera prevention’s ultimate aim.  For example, the WHO is concerned with cholera prevention and control efforts.  Providing medical treatment to individuals, clean water, and essential handwashing are among some basic hygiene practices promoted by the WHO to combat cholera.  

In recent years there have been advancements in research and studies on diagnosing and treating cholera. (Lessler et al., 2018).   Developing better sanitation interventions and water treatment strategies have effectively reduced the risk of cholera transmission. (Lessler et al., 2018).  Another notable strategy is the utilization of oral cholera vaccines (OCVs) to prevent cholera transmission.  Today international organizations such as the WHO is determined to coordinate mass vaccination campaigns to reduce the cholera burden in the coming years.  This strategy has been halted as OCV stockpiles have been depleted due to multiple outbreaks and vaccine manufacturing interruptions.  From all indications, the continued development of new research and strategies reflects the changing environment and political, economic, and social concerns about the disease. 

Overall, the government can address the prevalence of cholera outbreaks in rural and slum areas of Uganda by thoroughly understanding the social determinants of health.  Some of the social determinants of health associated with cholera include poverty, lack of education, access to clean water, poor sanitation, and cultural practices,  By addressing these factors, it is easier to develop a comprehensive approach that will facilitate improved health outcomes and reduced cholera outbreaks. The key to the success of these endeavors leads directly to the country’s youth population. Training, educating, and generating employment in the key areas will improve outcomes.  

NURS FPX 8014 Assessment 2 Global Issue Problem Description

References

Belay, D. G., Asratie, M. H., Aragaw, F. M., & al., E. (2022). Open defecation practice and its determinants among households in sub-Saharan Africa: pooled prevalence and multilevel analysis of 33 sub-Saharan Africa countries demographic and health survey. Tropical Med Health, 50(28). https://doi.org/10.1186/s41182-022-00416-5

Bwire, G., Debes, A., Orach, C., Kagirita, A., Ram, M., Komuakech, H., Voeylein, J., Buyinza, A., Obala, T., Brooks, W. A., & Sack, D. (2018). Environmental Surveillance of Vibrio Cholerae 01/0139 in Five African Great Lakes And Other Major Water Sources in Uganda. Frontiers in Microbiology, 9. https://doi.org/10.3389/fmicb.2018.01560

Cholera. (n.d.). Gapminder. https://www,gapminder.org

Debes, A. K., Murt, K. N., Waswa, E., Githinji, G., Umuro, M., Mbogori, C., Roskosky, M., Ram, M., Shaffer, A., Sack, D., & Boru, W. (2021). Laboratory and Field Evaluation of the Crystal VC-01 Cholera Rapid Diagnostic Test. The American Journal of Tropical Medicine and Hygiene, 104(6), 217–2023. https://doi.org/10.4269/ajtmh.20-1280

Deoshatwar, A., Salve, D., Gopalkrishna, V., Kumar, A., Barve, U., Joshi, M., Kalendra, S., Dhembre, V., Maheshwari, S., & Viswanathan, R. (2022). Evidence-Based Health Behavior Interventions for Cholera: Lessons from an Outbreak Investigation in India. The American Journal of Tropical Medicine and Hygeine, 10(1), 229–232. https://doi.org/10.4269/ajtmh.21-0625

Global Task Force on Cholera Control, 2017 Ending Cholera: A Global Roadmap to 2030. (n.d.). World Health Organization. Retrieved February 16, 2023, from who.int/cholera/publications/global-roadmap

Lessler, J., Moore, S., Luquero, F., McKay, H., Grass, R., Henkins, M., Mengel, M., Dunoyer, J., Mbanyombe, M., Lee, E., Dijinarey, M., Sudre, B., Bompangue, D., Fraser, R., Abubakur, A., Perea, W., Legros, D., & Azman, A. (2018). Mapping the burden of Cholera in sub-Saharan Africa and implications for control: an analysis of data across geographical scales. The Lancet, 391(10133), 1908–1915. https://doi.org/10.1016/S0140-6736(17)33050-7

Medard, T., Yawe, B., & Bosco, O. (2022). Determinants of Demand for Private Health Insurance in Uganda. African Journal of Economic Review, 10(3). https://doi.org/10.22004/age.econsearch.imn.edu/record/33036

Munezero, E., & Manoukian, S. (2021). The social determinants of health and health seeking behaviors in populations affected by armed conflict: a systematic qualitative review. Medicine, Conflict and Survival, 37(4), 293–318. https://doi.org/10.1080/13623699.2021.197

Panda, S., Chatterjee, P., Deb, A., Kanungo, S., & Dutta, S. (2020). Preventing Cholera in India: Synthesizing evidence through systematic review for policy discussion on use of oral cholera vaccine. Vaccine, 38(Suppl 1), A148–A156. https://doi.org/10.1016/j.vaccine.2019.07.029

Ramamurthy, T., Mutreja, A., Weill, F. X., Das, B., Ghosh, A., & Nair, G. B. (2019). Revisiting the Global Epidemiology of Cholera in Conjunction with the Genomics of Vibrio cholerae. Frontiers in Public Health, 7(203). https://doi.org/10.3389/fpubh.2019.200203

Sack, D. (2013). A new era in the history of cholera: the road to elimination. International Journal of Epidemiology, 42(6), 1537–1540. https://doi.org/10.1093/ije/dyt229

Saez, J. P., Lessler, J., Lee, E., Laquero, F., Malembaka, E., & Finger, F. (2022). The seasonality of cholera in subs-Saharan Africa: a statistical modeling study. The Lancet, 10(6), E831–E839. https://doi.org/10.1016/S2214-109X(22)00007-9

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The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. NURS FPX 8014 Assessment 2 Global Issue Problem Description

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. NURS FPX 8014 Assessment 2 Global Issue Problem Description

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