Epidemic cholera in Mali: high mortality and multiple routes of transmission in a famine area

During the 1984 cholera epidemic in Mali, 1793 cases and 406 deaths were reported, a death-to-case ratio of 23%. In four affected villages, the mean clinical attack rate was 17·5 and 29% of affected persons died. In 66% of cases the illness began more than 48 h after the village outbreak began, when supplies from outside the village were potentially available. Deaths occurred because patients failed to seek care or received only limited rehydration therapy when they did. Case-control studies identified two routes of transmission: drinking water from one well in a village outside the drought area, and eating left-over millet gruel in a droughtaffected village. Drought-related scarcity of curdled milk may permit millet gruel to be a vehicle for cholera. Cholera mortality in the Sahel could be greatly reduced by rapid intervention in affected villages, wide distribution of effective rehydration materials, and educating the population to seek treatment quickly.