[Mass antibiotic prophylaxis against cholera in the New Bell central prison in Douala during the 2004 epidemic]

In early January 2004, cases of severe watery diarrhea were reported in Douala, the economic capital of Cameroon (estimated population: 2.4 million inhabitants). Three stool samples examined at the Cameroon National Reference Laboratory grew Vibrio cholerae serogroup O1, later identified by the Pasteur Institute in Paris, France, as serotype Inaba. On 19 January, the provincial health authorities declared an outbreak of cholera. The epidemic lasted until that September. In all, 5,020 cholera cases were reported, and 69 deaths from cholera among hospital patients. The overall attack rate for Douala was 209 cases per 100,000 inhabitants, with a case-fatality ratio of 1.37%. New Bell Central Prison, the sole penitentiary facility for Douala, is situated in the center of the town, near the biggest market. It was originally built in 1930 for 700 prisoners but now houses an average of roughly 3,100 inmates. Living and sanitary conditions in the prison are deplorable. Half of the cells house more than 150 inmates with a surface area of less than 0.20 m2 per inmate. Approximately 400 people--visitors, new admissions, and discharged prisoners--enter and leave the prison. In February 2004, five suspected cases of cholera were reported in the prison's hospital ward. Immediate measures were taken to prevent an explosive spread of cholera within the prison: a) suspected cases were treated with rehydration therapy, antibiotics, and isolation; and b) preventive antibiotic treatment, consisting of a single 300-mg dose of doxycycline, was administered to all 3,036 prisoners and 164 prison staff members. No significant side effects were observed. Despite a reinforced surveillance system, no new cholera cases were reported except two suspected cases in June 2004 (four months later), and their diagnoses could not be confirmed. A cholera epidemic in an urban area mandates rigorous epidemiological surveillance system and provisions for safety stocks of therapeutic and prophylactic drugs in closed at-risk settings, such as prisons. Collective single-dose prophylaxis with an antibiotic the efficacy of which is confirmed by in vitro antibiotic susceptibility testing can provide immediate protection not available by other preventive measures (education, sanitation, immunization) against a cholera epidemic in a prison.