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Ngere P, Langat D, Ngere I, Dawa J, Okunga E, Nasimiyu C, Kiama C, Lokamar P, Ngunu C, Makayotto L, Njenga MK, Osoro E. A protracted cholera outbreak in Nairobi City County accentuated by mass gathering events, Kenya, 2017. PLoS One 2024; 19:e0297324. [PMID: 39208189 PMCID: PMC11361576 DOI: 10.1371/journal.pone.0297324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 07/23/2024] [Indexed: 09/04/2024] Open
Abstract
Cholera continues to cause many outbreaks in low and middle-income countries due to inadequate water, sanitation, and hygiene services. We describe a protracted cholera outbreak in Nairobi City County, Kenya in 2017. We reviewed the cholera outbreak line lists from Nairobi City County in 2017 to determine its extent and factors associated with death. A suspected case of cholera was any person aged >2 years old who had acute watery diarrhea, nausea, or vomiting, whereas a confirmed case was where Vibrio cholerae was isolated from the stool specimen. We summarized cases using means for continuous variables and proportions for categorical variables. Associations between admission status, sex, age, residence, time to care seeking, and outbreak settings; and cholera associated deaths were assessed using odds ratio (OR) with 95% confidence interval (CI). Of the 2,737 cholera cases reported, we analyzed 2,347 (85.7%) cases including 1,364 (58.1%) outpatients, 1,724 (73.5%) not associated with mass gathering events, 1,356 (57.8%) male and 2,202 (93.8%) aged ≥5 years, and 35 deaths (case fatality rate: 1.5%). Cases were reported from all the Sub Counties of Nairobi City County with an overall county attack rate of 50 per 100,000 people. Vibrio cholerae Ogawa serotype was isolated from 78 (34.8%) of the 224 specimens tested and all isolates were sensitive to tetracycline and levofloxacin but resistant to amikacin. The odds of cholera-related deaths was lower among outpatient cases (aOR: 0.35; [95% CI: 0.17-0.72]), age ≥5 years old (aOR: 0.21 [95% CI: 0.09-0.55]), and mass gathering events (aOR: 0.26 [95% CI: 0.07-0.91]) while threefold higher odds among male (aOR: 3.04 [95% CI: 1.30-7.13]). Nairobi City County experienced a protracted and widespread cholera outbreak with a high case fatality rate in 2017.
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Affiliation(s)
- Philip Ngere
- Washington State University Global Health Program, Nairobi City, Kenya
- Division of Disease Surveillance and Response, Ministry of Health, Nairobi City, Kenya
| | - Daniel Langat
- Division of Disease Surveillance and Response, Ministry of Health, Nairobi City, Kenya
| | - Isaac Ngere
- Washington State University Global Health Program, Nairobi City, Kenya
| | - Jeanette Dawa
- Washington State University Global Health Program, Nairobi City, Kenya
| | - Emmanuel Okunga
- Division of Disease Surveillance and Response, Ministry of Health, Nairobi City, Kenya
| | - Carolyne Nasimiyu
- Washington State University Global Health Program, Nairobi City, Kenya
| | - Catherine Kiama
- Washington State University Global Health Program, Nairobi City, Kenya
| | - Peter Lokamar
- National Public Health Laboratory Services, Ministry of Health, Nairobi City, Kenya
| | - Carol Ngunu
- Department of Health Services, Nairobi City County Government, Nairobi City, Kenya
| | - Lyndah Makayotto
- Division of Disease Surveillance and Response, Ministry of Health, Nairobi City, Kenya
| | - M. Kariuki Njenga
- Washington State University Global Health Program, Nairobi City, Kenya
- Paul G Allen School for Global Health, Washington State University, Pullman, WA, United States of America
| | - Eric Osoro
- Washington State University Global Health Program, Nairobi City, Kenya
- Paul G Allen School for Global Health, Washington State University, Pullman, WA, United States of America
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Armando CJ, Rocklöv J, Sidat M, Tozan Y, Mavume AF, Bunker A, Sewe MO. Spatial-temporal analysis of climate and socioeconomic conditions on cholera incidence in Mozambique from 2000 to 2018: an ecological longitudinal retrospective study. BMJ Open 2024; 14:e082503. [PMID: 39160100 PMCID: PMC11337674 DOI: 10.1136/bmjopen-2023-082503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 07/30/2024] [Indexed: 08/21/2024] Open
Abstract
OBJECTIVES This study aims to assess both socioeconomic and climatic factors of cholera morbidity in Mozambique considering both spatial and temporal dimensions. DESIGN An ecological longitudinal retrospective study using monthly provincial cholera cases from Mozambican Ministry of Health between 2000 and 2018. The cholera cases were linked to socioeconomic data from Mozambique Demographic and Health Surveys conducted in the period 2000-2018 and climatic data; relative humidity (RH), mean temperature, precipitation and Normalised Difference Vegetation Index (NDVI). A negative binomial regression model in a Bayesian framework was used to model cholera incidence while adjusting for the spatiotemporal covariance, lagged effect of environmental factors and the socioeconomic indicators. SETTING Eleven provinces in Mozambique. RESULTS Over the 19-year period, a total of 153 941 cholera cases were notified to the surveillance system in Mozambique. Risk of cholera increased with higher monthly mean temperatures above 24°C in comparison to the reference mean temperature of 23°C. At mean temperature of 19°C, cholera risk was higher at a lag of 5-6 months. At a shorter lag of 1 month, precipitation of 223.3 mm resulted in an 57% increase in cholera risk (relative risk, RR 1.57 (95% CI 1.06 to 2.31)). Cholera risk was greatest at 3 lag months with monthly NDVI of 0.137 (RR 1.220 (95% CI 1.042 to 1.430)), compared with the reference value of 0.2. At an RH of 54%, cholera RR was increased by 62% (RR 1.620 (95% CI 1.124 to 2.342)) at a lag of 4 months. We found that ownership of radio RR 0.29, (95% CI 0.109 to 0.776) and mobile phones RR 0.262 (95% CI 0.097 to 0.711) were significantly associated with low cholera risk. CONCLUSION The derived lagged patterns can provide appropriate lead times in a climate-driven cholera early warning system that could contribute to the prevention and management of outbreaks.
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Affiliation(s)
- Chaibo Jose Armando
- Department of Public Health and Clinical Medicine, Sustainable Health Section, Umeå University, Umea, Sweden
- Eduardo Mondlane University, Maputo, Mozambique
| | - Joacim Rocklöv
- Department of Public Health and Clinical Medicine, Sustainable Health Section, Umeå University, Umea, Sweden
- Heidelberg Institute of Global Health and Interdisciplinary Centre for Scientific Computing, Heidelberg University, Heidelberg, Germany
| | | | - Yesim Tozan
- School of Global Public Health, NYU, New York, New York, USA
| | | | - Aditi Bunker
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Maquins Odhiambo Sewe
- Department of Public Health and Clinical Medicine, Sustainable Health Section, Umeå University, Umea, Sweden
- Universitatsklinikum Heidelberg Heidelberg Institute of Global Health, Heidelberg, Germany
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Roy D, Mondal TR, Indwar P. Outbreak of cholera due to contaminated pond water utilisation in a rural area of West Bengal, India, 2021. Int J Hyg Environ Health 2024; 261:114409. [PMID: 38943722 DOI: 10.1016/j.ijheh.2024.114409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/01/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND On March 31, 2021, an outbreak of diarrhoeal disease was reported in Dangapara village of Purba Bardhaman district, West Bengal, India. The outbreak was investigated to estimate the magnitude, identify aetiological agents and source of infection, and guide prevention control measures. METHODS We did an active search for case patients at Dangapara village. We excluded children under five years of age from the epidemiological analysis. We described the outbreak by time, place, and person. We conducted a case control study with 133 controls and 65 cases. Water samples from different sources and rectal swabs from case patients were collected and sent for laboratory investigations. RESULTS We identified 95 case patients among 330 residents of Dangapara village (attack rate 29 %). Three stool samples were positive for Vibrio cholerae, and two pond water samples were contaminated with coliform organisms. Washing utensils [adjusted odds ratio (AOR): 69.8, (95% confidence interval (CI) 6.5-749.5)] and taking a bath in pond water [AOR: 3.4, (95% CI 1.2-9)] were associated with increased risk of illness. About 97% of cases were attributed to washing utensils in pond water. Washing hands before taking food was associated with a lower risk of developing disease with AOR: 0.1 (95% CI 0.03-0.33). CONCLUSION A cholera outbreak occurred among residents of Dangapara village due to theuse of contaminated pond water for washing utensils and bathing. Prompt management of cases and immediate discontinuation of pond water use stopped the outbreak.
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Affiliation(s)
- Dhiraj Roy
- Baruipur Sub Divisional & Super Speciality Hospital, West Bengal Public Health Cum Administrative Services, West Bengal, India
| | - Tanima Roy Mondal
- R.G. Kar Medical College & Hospital, West Bengal Medical Education Service, West Bengal, India
| | - Pallavi Indwar
- ICMR-National Institute of Cholera and Enteric Diseases, Beliaghata, Kolkata, India.
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Chaguza C, Chibwe I, Chaima D, Musicha P, Ndeketa L, Kasambara W, Mhango C, Mseka UL, Bitilinyu-Bangoh J, Mvula B, Kipandula W, Bonongwe P, Munthali RJ, Ngwira S, Mwendera CA, Kalizang'oma A, Jambo KC, Kambalame D, Kamng'ona AW, Steele AD, Chauma-Mwale A, Hungerford D, Kagoli M, Nyaga MM, Dube Q, French N, Msefula CL, Cunliffe NA, Jere KC. Genomic insights into the 2022-2023Vibrio cholerae outbreak in Malawi. Nat Commun 2024; 15:6291. [PMID: 39060226 PMCID: PMC11282309 DOI: 10.1038/s41467-024-50484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Malawi experienced its deadliest Vibrio cholerae (Vc) outbreak following devastating cyclones, with >58,000 cases and >1700 deaths reported between March 2022 and May 2023. Here, we use population genomics to investigate the attributes and origin of the Malawi 2022-2023 Vc outbreak isolates. Our results demonstrate the predominance of ST69 clone, also known as the seventh cholera pandemic El Tor (7PET) lineage, expressing O1 Ogawa (~ 80%) serotype followed by Inaba (~ 16%) and sporadic non-O1/non-7PET serogroups (~ 4%). Phylogenetic reconstruction revealed that the Malawi outbreak strains correspond to a recent importation from Asia into Africa (sublineage AFR15). These isolates harboured known antimicrobial resistance and virulence elements, notably the ICEGEN/ICEVchHai1/ICEVchind5 SXT/R391-like integrative conjugative elements and a CTXφ prophage with the ctxB7 genotype compared to historical Malawian Vc isolates. These data suggest that the devastating cyclones coupled with the recent importation of 7PET serogroup O1 strains, may explain the magnitude of the 2022-2023 cholera outbreak in Malawi.
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Affiliation(s)
- Chrispin Chaguza
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, CT, USA.
- Yale Institute for Global Health, Yale University, New Haven, CT, USA.
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK.
- NIHR Mucosal Pathogens Research Unit, Research Department of Infection, Division of Infection and Immunity, University College London, London, UK.
- Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, UK.
| | - Innocent Chibwe
- Public Health Institute of Malawi, Ministry of Health, Lilongwe, Malawi
| | - David Chaima
- Department of Pathology, School of Medicine and Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Patrick Musicha
- Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, UK
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | - Latif Ndeketa
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | | | | | - Upendo L Mseka
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | | | - Bernard Mvula
- Public Health Institute of Malawi, Ministry of Health, Lilongwe, Malawi
| | - Wakisa Kipandula
- Department of Medical Laboratory Sciences, Faculty of Biomedical Sciences and Health profession, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Patrick Bonongwe
- Ministry of Health, Balaka District Hospital, Balaka, Machinga, Malawi
| | - Richard J Munthali
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Selemani Ngwira
- Public Health Institute of Malawi, Ministry of Health, Lilongwe, Malawi
| | - Chikondi A Mwendera
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Akuzike Kalizang'oma
- NIHR Mucosal Pathogens Research Unit, Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | - Kondwani C Jambo
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Arox W Kamng'ona
- Department of Biomedical Sciences, School of Life Sciences and Allied Health Professions, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - A Duncan Steele
- Diarrhoeal Pathogens Research Unit, Sefako Makgatho Health Sciences University, Medunsa, 0204, Pretoria, South Africa
| | | | - Daniel Hungerford
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK
| | - Matthew Kagoli
- Public Health Institute of Malawi, Ministry of Health, Lilongwe, Malawi
| | - Martin M Nyaga
- Next Generation Sequencing Unit and Division of Virology, Faculty of Health Sciences, University of the Free State, Bloemfontein, 9300, South Africa
| | - Queen Dube
- Malawi Ministry of Health, Lilongwe, Malawi
| | - Neil French
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | - Chisomo L Msefula
- Department of Pathology, School of Medicine and Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nigel A Cunliffe
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK
- NIHR Global Health Research Group on Gastrointestinal Infections, University of Liverpool, Liverpool, UK
| | - Khuzwayo C Jere
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK.
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi.
- Department of Medical Laboratory Sciences, Faculty of Biomedical Sciences and Health profession, Kamuzu University of Health Sciences, Blantyre, Malawi.
- NIHR Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, UK.
- NIHR Global Health Research Group on Gastrointestinal Infections, University of Liverpool, Liverpool, UK.
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Figuereo S, Yoon I, Kaddu SS, Lubogo M, Baruch J, Hossain AA, Mohamed SI, Abubakar AHA, Mohamud KM, Malik SMMR. Cost of Cholera for Households and Health Facilities, Somalia. J Epidemiol Glob Health 2024:10.1007/s44197-024-00278-6. [PMID: 39023718 DOI: 10.1007/s44197-024-00278-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION Cholera remains a substantial public health challenge in Somalia. Ongoing droughts in the country have caused significant outbreaks which have negatively affected the lives of many individuals and overwhelmed health facilities. We aimed to estimate the costs associated with cholera cases for households and health facilities in Somalia. METHODS This cost-of-illness study was conducted in five cholera treatment centres in Somalia and 400 patients treated in these facilities. Data collection took place during October and November 2023. Given that a significant portion of the patients were children, we interviewed their caregivers to gather cost data. We interviewed staff at the centres and the patients. The data obtained from the household questionnaire covered direct (medical and non-medical) and indirect (lost wages) costs, while direct costs were estimated for the health facility (personnel salaries, drugs and consumables used to treat a patient, and utility expenses). All costs were calculated in US dollars (USD), using 2023 as the base year for the estimation. RESULTS The average total cost of a cholera episode for a household was US$ 33.94 (2023 USD), with 50.4% (US$ 17.12) being direct costs and 49.6% (US$ 16.82) indirect costs. The average total cost for a health facility to treat an episode of cholera was US$ 82.65. The overall average cost to households and health facilities was US$ 116.59. The average length of stay for a patient was 3.08 days. In the households, patients aged 41 years and older incurred the highest mean total cost (US$ 73.90) while patients younger than 5 years had the lowest cost (US$ 21.02). Additionally, 61.8% of households had to use family savings to cover the cost of the cholera episode, while 14.5% had to borrow money. Most patients (71.8%) were younger than 16 years- 45.3% were 5 years or younger- and 94.0% had never received a cholera vaccine. CONCLUSION Our study suggests that preventing one cholera episode in Somalia could avert substantial losses for both the households and cholera treatment centres. The findings shed light on the expenses associated with cholera that extend beyond healthcare, including substantial direct and indirect costs borne by households. Preventing cholera cases could lead to a decrease in this economic burden, consequently our study supports the need for preventive measures.
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Affiliation(s)
- Salvador Figuereo
- World Health Organization, Somalia Country Office, Mogadishu, Somalia.
| | - Ian Yoon
- World Health Organization, Headquarters, Geneva, Switzerland
| | | | - Mutaawe Lubogo
- World Health Organization, Somalia Country Office, Mogadishu, Somalia
| | - Joaquin Baruch
- World Health Organization, Somalia Country Office, Mogadishu, Somalia
| | - Asm Amjad Hossain
- World Health Organization, Somalia Country Office, Mogadishu, Somalia
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Valerio MGP, Laher B, Phuka J, Lichand G, Paolotti D, Leal Neto O. Participatory Disease Surveillance for the Early Detection of Cholera-Like Diarrheal Disease Outbreaks in Rural Villages in Malawi: Prospective Cohort Study. JMIR Public Health Surveill 2024; 10:e49539. [PMID: 39012690 PMCID: PMC11289577 DOI: 10.2196/49539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 02/16/2024] [Accepted: 05/16/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years. OBJECTIVE This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi. METHODS This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies' rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea. RESULTS During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively. CONCLUSIONS PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.
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Affiliation(s)
| | - Beverly Laher
- Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - John Phuka
- Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Guilherme Lichand
- Graduate School of Education, Stanford University, Stanford, CA, United States
| | | | - Onicio Leal Neto
- Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, United States
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Hailu D, Jeon Y, Gedefaw A, Kim JH, Mraidi R, Getahun T, Mogeni OD, Mesfin Getachew E, Jang GH, Mukasa D, Pak GD, Kim DR, Ayele Abebe S, Yeshitela B, Edosa M, Worku Demlie Y, Park SE, Teferi M. Dissecting Water, Sanitation, and Hygiene (WaSH) to Assess Risk Factors for Cholera in Shashemene, Oromia Region, Ethiopia. Clin Infect Dis 2024; 79:S53-S62. [PMID: 38996037 PMCID: PMC11244206 DOI: 10.1093/cid/ciae274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Cholera outbreaks have afflicted Ethiopia, with nearly 100 000 cases and 1030 deaths reported from 2015 to 2023, emphasizing the critical need to understand water, sanitation, and hygiene (WaSH) risk factors. METHODS We conducted a cross-sectional household (HH) survey among 870 HHs in Shashemene Town and Shashemene Woreda, alongside extracting retrospective cholera case data from the Ethiopian Public Health Institute database. Relationships between WaSH and sociodemographic/economic-levels of HHs were examined. WaSH status and cholera attack rates (ARs) were described at kebele-level using geospatial mapping, and their association was statistically analyzed. RESULTS Access to basic drinking water, sanitation, and hygiene facilities was limited, with 67.5% (95% confidence interval, 64.4-70.6), 73.4% (70.3-76.3), and 30.3% (27.3-33.3) of HHs having access, respectively. Better WaSH practices were associated with urban residence (adjusted odds ratio, 1.7, [95% confidence interval, 1.1-2.7]), higher educational levels (2.7 [1.2-5.8]), and wealth (2.5 [1.6-4.0]). The association between cholera ARs and at least basic WaSH status was not statistically significant (multiple R2 = 0.13; P = .36), although localized effects were suggested for sanitation (Moran I = 0.22; P = .024). CONCLUSIONS Addressing gaps in WaSH access and hygiene practices is crucial for reducing cholera risk. Further analyses with meaningful covariates and increased sample sizes are necessary to understand the association between cholera AR and specific WaSH components.
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Affiliation(s)
- Dejene Hailu
- Clinical, Assessment, Regulatory, Evaluation (CARE) Unit, International Vaccine Institute, Seoul, Republic of Korea
- School of Public Health, Hawassa University, Hawassa, Ethiopia
| | - Yeonji Jeon
- Clinical, Assessment, Regulatory, Evaluation (CARE) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Abel Gedefaw
- Clinical, Assessment, Regulatory, Evaluation (CARE) Unit, International Vaccine Institute, Seoul, Republic of Korea
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Jong-Hoon Kim
- Epidemiology, Public Health, Impact (EPIC) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Ramzi Mraidi
- Epidemiology, Public Health, Impact (EPIC) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Tomas Getahun
- Clinical Trials Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Ondari D Mogeni
- Clinical, Assessment, Regulatory, Evaluation (CARE) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | | | - Geun Hyeog Jang
- Epidemiology, Public Health, Impact (EPIC) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - David Mukasa
- Epidemiology, Public Health, Impact (EPIC) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Gi Deok Pak
- Epidemiology, Public Health, Impact (EPIC) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Deok Ryun Kim
- Epidemiology, Public Health, Impact (EPIC) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Samuyel Ayele Abebe
- Statistics and Data Management Department, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Biruk Yeshitela
- Bacterial and Viral Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Moti Edosa
- Public Health Emergency Management, Ethiopia Public Health Institute, Addis Ababa, Ethiopia
| | - Yeshambel Worku Demlie
- Public Health Emergency Management, Ethiopia Public Health Institute, Addis Ababa, Ethiopia
| | - Se Eun Park
- Clinical, Assessment, Regulatory, Evaluation (CARE) Unit, International Vaccine Institute, Seoul, Republic of Korea
- Department of Global Health and Disease Control, Yonsei University Graduate School of Public Health, Seoul, Republic of Korea
| | - Mekonnen Teferi
- Clinical Trials Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
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George CM, Namunesha A, Felicien W, Endres K, Luo W, Bisimwa L, Williams C, Bisimwa JC, Sanvura P, Perin J, Bengehya J, Maheshe G, Sack DA, Cikomola C, Mwishingo A. Evaluation of a rapid diagnostic test for detection of Vibrio cholerae O1 in the Democratic Republic of the Congo: Preventative intervention for cholera for 7 days (PICHA7 program). Trop Med Int Health 2024; 29:594-598. [PMID: 38773948 DOI: 10.1111/tmi.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
OBJECTIVE Globally, there are estimated to be 2.9 million cholera cases annually. Early detection of cholera outbreaks is crucial for resource allocation for case management and for targeted interventions to be delivered to stop the spread of cholera. In resource limited settings such as Eastern Democratic Republic of the Congo (DRC), there is often limited laboratory capacity for analysing stool samples for cholera by bacterial culture. Therefore, rapid diagnostic tests (RDTs) for cholera present a promising tool to rapidly test stool samples in a health facility setting for cholera. Our objective is to evaluate the Crystal VC O1 RDT for cholera detection compared with bacterial culture and polymerase chain reaction (PCR) for Vibrio cholerae. METHODS From March 2020 to December 2022, stool samples were collected from 644 diarrhoea patients admitted to 94 health facilities in Bukavu in Eastern DRC. Patient stool samples were analysed by Crystal VC O1 RDT for cholera and by bacterial culture and PCR for V. cholerae O1. RESULTS Twenty six percent of diarrhoea patients (166/644) had stool samples positive for cholera by RDT, and 24% (152/644) had stool samples positive for V. cholerae O1 by bacterial culture or PCR. The overall specificity and sensitivity of the Crystal VC O1 RDT by direct testing was 94% (95% confidence interval [CI]: 92%-96%) and 90% (95% CI, 84%-94%), respectively, when compared with either a positive result by bacterial culture or PCR. CONCLUSION Our findings suggest that the Crystal VC O1 RDT presents a promising tool for cholera surveillance in this cholera endemic setting in sub-Saharan Africa.
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Affiliation(s)
- Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alves Namunesha
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Willy Felicien
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Kelly Endres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Wensheng Luo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lucien Bisimwa
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Camille Williams
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jean-Claude Bisimwa
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Presence Sanvura
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Justin Bengehya
- Bureau de l'Information Sanitaire, Surveillance Epidémiologique et Recherche Scientifique Division, Provinciale de la Santé/Sud Kivu, Ministère de la Santé Publique, Hygiène et Prévention, Bukavu, Democratic Republic of the Congo
| | - Ghislain Maheshe
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cirhuza Cikomola
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Alain Mwishingo
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
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Gallandat K, Macdougall A, Jeandron A, Mufitini Saidi J, Bashige Rumedeka B, Malembaka EB, Azman AS, Bompangue D, Cousens S, Allen E, Cumming O. Improved water supply infrastructure to reduce acute diarrhoeal diseases and cholera in Uvira, Democratic Republic of the Congo: Results and lessons learned from a pragmatic trial. PLoS Negl Trop Dis 2024; 18:e0012265. [PMID: 38959264 PMCID: PMC11251581 DOI: 10.1371/journal.pntd.0012265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 07/16/2024] [Accepted: 06/02/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Safely managed drinking water is critical to prevent diarrhoeal diseases, including cholera, but evidence on the effectiveness of piped water supply in reducing these diseases in low-income and complex emergency settings remains scarce. METHODS We conducted a trial of water supply infrastructure improvements in Uvira (DRC). Our primary objective was to estimate the relationship between a composite index of water service quality and the monthly number of suspected cholera cases admitted to treatment facilities and, as a secondary analysis, the number of cases confirmed by rapid diagnostic tests. Other exposures included the quantity of supplied water and service continuity. We used Poisson generalised linear models with generalised estimating equations to estimate incidence rate ratios. FINDINGS Associations between suspected cholera incidence and water service quality (RR 0·86, 95% CI 0·73-1·01), quantity (RR 0·80, 95% CI 0·62-1·02) and continuity (RR 0·81, 95% CI 0·77-0·86) were estimated. The magnitudes of the associations were similar between confirmed cholera incidence and water service quality (RR 0·84, 95% CI 0·73-0·97), quantity (RR 0·76, 95% CI 0·61-0·94) and continuity (RR 0·75, 95% CI 0·69-0·81). These results suggest that an additional 5 L/user/day or 1.2 hour per day of water production could reduce confirmed cholera by 24% (95% CI 6-39%) and 25% (95% CI 19-31%), respectively. INTERPRETATION Ensuring a sufficient and continuous piped water supply may substantially reduce the burden of endemic cholera and diarrhoeal diseases but evaluating this rigorously is challenging. Pragmatic strategies are needed for public health research on complex interventions in protracted emergency settings. TRIAL REGISTRATION The trial is registered in ClinicalTrials.gov ID NCT02928341. https://classic.clinicaltrials.gov/ct2/show/NCT02928341.
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Affiliation(s)
- Karin Gallandat
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amy Macdougall
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aurélie Jeandron
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jaime Mufitini Saidi
- Ministère de la Santé Publique, Division Provinciale de la Santé du Sud-Kivu, Zone de Santé d’Uvira, Uvira, Democratic Republic of Congo
| | - Baron Bashige Rumedeka
- Ministère de la Santé Publique, Division Provinciale de la Santé du Sud-Kivu, Zone de Santé d’Uvira, Uvira, Democratic Republic of Congo
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
- Centre for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Didier Bompangue
- Service d’Ecologie et Contrôle des Maladies Infectieuses, Faculté de Médecine, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Simon Cousens
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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10
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Girotto CD, Behzadian K, Musah A, Chen AS, Djordjević S, Nichols G, Campos LC. Analysis of environmental factors influencing endemic cholera risks in sub-Saharan Africa. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 926:171896. [PMID: 38522541 DOI: 10.1016/j.scitotenv.2024.171896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 02/21/2024] [Accepted: 03/20/2024] [Indexed: 03/26/2024]
Abstract
The recurring cholera outbreaks in sub-Saharan Africa are of growing concern, especially considering the potential acceleration in the global trend of larger and more lethal cholera outbreaks due to the impacts of climate change. However, there is a scarcity of evidence-based research addressing the environmental and infrastructure factors that sustain cholera recurrence in Africa. This study adopts a statistical approach to investigate over two decades of endemic cholera outbreaks and their relationship with five environmental factors: water provision, sanitation provision, raising temperatures, increased rainfall and GDP. The analysis covers thirteen of the forty-two countries in the mainland sub-Saharan region, collectively representing one-third of the region's territory and half of its population. This breadth enables the findings to be generalised at a regional level. Results from all analyses consistently associate water provision with cholera reduction. The stratified model links increased water provision with a reduction in cholera risk that ranged from 4.2 % to 84.1 % among eight countries (out of 13 countries) as well as a reduction of such risk that ranged from 9.8 % to 68.9 % when there is increased sanitation provision, which was observed in nine countries (out of 13). These results indicate that the population's limited access to water and sanitation, as well as the rise in temperatures, are critical infrastructure and environmental factors contributing to endemic cholera and the heightened risk of outbreaks across the sub-Saharan region. Therefore, these are key areas for targeted interventions and cross-border collaboration to enhance resilience to outbreaks and lead to the end of endemic cholera in the region. However, it is important to interpret the results of this study with caution; hence, further investigation is recommended to conduct a more detailed analysis of the impact of infrastructure and environmental factors on reducing cholera risk.
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Affiliation(s)
- Cristiane D Girotto
- School of Computing and Engineering, University of West London, St Mary's Road, Ealing, London W5 5RF, UK; Centre for Urban Sustainability and Resilience, Department of Civil, Environmental and Geomatic Engineering, University College London, Gower St, London WC1E 6BT, UK
| | - Kourosh Behzadian
- School of Computing and Engineering, University of West London, St Mary's Road, Ealing, London W5 5RF, UK; Centre for Urban Sustainability and Resilience, Department of Civil, Environmental and Geomatic Engineering, University College London, Gower St, London WC1E 6BT, UK
| | - Anwar Musah
- Geospatial Analytics and Computing (GSAC), Dept of Geography, University College London, Gower St, London WC1E 6BT, UK
| | - Albert S Chen
- Centre for Water Systems, University of Exeter, Harrison Building, Streatham Campus, N Park Rd, Exeter EX4 4QF, UK
| | - Slobodan Djordjević
- Centre for Water Systems, University of Exeter, Harrison Building, Streatham Campus, N Park Rd, Exeter EX4 4QF, UK
| | - Gordon Nichols
- Centre for Radiation Chemicals and Environmental Hazards, Public Health England, Chilton, Oxon OX11 0RQ, UK
| | - Luiza C Campos
- Centre for Urban Sustainability and Resilience, Department of Civil, Environmental and Geomatic Engineering, University College London, Gower St, London WC1E 6BT, UK.
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11
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OKeeffe J, Salem-Bango L, Desjardins MR, Lantagne D, Altare C, Kaur G, Heath T, Rangaiya K, Obroh POO, Audu A, Lecuyot B, Zoungrana T, Ihemezue EE, Aye S, Sikder M, Doocy S, Wang Q, Xiao M, Spiegel PB. Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria. PLoS Med 2024; 21:e1004404. [PMID: 38728366 PMCID: PMC11149837 DOI: 10.1371/journal.pmed.1004404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 06/04/2024] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Cholera outbreaks are on the rise globally, with conflict-affected settings particularly at risk. Case-area targeted interventions (CATIs), a strategy whereby teams provide a package of interventions to case and neighboring households within a predefined "ring," are increasingly employed in cholera responses. However, evidence on their ability to attenuate incidence is limited. METHODS AND FINDINGS We conducted a prospective observational cohort study in 3 conflict-affected states in Nigeria in 2021. Enumerators within rapid response teams observed CATI implementation during a cholera outbreak and collected data on household demographics; existing water, sanitation, and hygiene (WASH) infrastructure; and CATI interventions. Descriptive statistics showed that CATIs were delivered to 46,864 case and neighbor households, with 80.0% of cases and 33.5% of neighbors receiving all intended supplies and activities, in a context with operational challenges of population density, supply stock outs, and security constraints. We then applied prospective Poisson space-time scan statistics (STSS) across 3 models for each state: (1) an unadjusted model with case and population data; (2) an environmentally adjusted model adjusting for distance to cholera treatment centers and existing WASH infrastructure (improved water source, improved latrine, and handwashing station); and (3) a fully adjusted model adjusting for environmental and CATI variables (supply of Aquatabs and soap, hygiene promotion, bedding and latrine disinfection activities, ring coverage, and response timeliness). We ran the STSS each day of our study period to evaluate the space-time dynamics of the cholera outbreaks. Compared to the unadjusted model, significant cholera clustering was attenuated in the environmentally adjusted model (from 572 to 18 clusters) but there was still risk of cholera transmission. Two states still yielded significant clusters (range 8-10 total clusters, relative risk of 2.2-5.5, 16.6-19.9 day duration, including 11.1-56.8 cholera cases). Cholera clustering was completely attenuated in the fully adjusted model, with no significant anomalous clusters across time and space. Associated measures including quantity, relative risk, significance, likelihood of recurrence, size, and duration of clusters reinforced the results. Key limitations include selection bias, remote data monitoring, and the lack of a control group. CONCLUSIONS CATIs were associated with significant reductions in cholera clustering in Northeast Nigeria despite operational challenges. Our results provide a strong justification for rapid implementation and scale-up CATIs in cholera-response, particularly in conflict settings where WASH access is often limited.
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Affiliation(s)
- Jennifer OKeeffe
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lindsay Salem-Bango
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael R. Desjardins
- Spatial Science for Public Health Center, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Daniele Lantagne
- Lancon Environmental, LLC, Somerville, Massachusetts, United States of America
| | - Chiara Altare
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Gurpreet Kaur
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | | | | | | | | | | | - Solomon Aye
- Solidarités International, Maiduguri, Nigeria
| | - Mustafa Sikder
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shannon Doocy
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Qiulin Wang
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Melody Xiao
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Paul B. Spiegel
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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12
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Systematic testing in cholera surveillance enhances vaccine impact and cost-effectiveness. Nat Med 2024; 30:950-951. [PMID: 38570700 DOI: 10.1038/s41591-024-02907-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
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13
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Semá Baltazar C, Langa JP, Baloi LD, Elias Chitio JJ, Manuel JA, Mboane RBJ, Assane S, Omar A, Manso M, Capitine I, Luiz N, Mukasa D, Jang GH, Park JY, Marks F, Mraidi R, Pak GD, Kim DR, Park SE. Cholera and diarrheal diseases in Cuamba District, Niassa Province, Mozambique: Systematic healthcare facility-based surveillance strengthening, characteristics of suspected cholera and diarrheal patients, and incidence of diarrheal diseases. PLoS Negl Trop Dis 2024; 18:e0011843. [PMID: 38687808 PMCID: PMC11086855 DOI: 10.1371/journal.pntd.0011843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/10/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Mozambique is one of the countries in Africa that is continuously at risk of cholera outbreaks due to poor sanitation, hygiene, and limited access to potable water in some districts. The Mozambique Cholera Prevention and Surveillance (MOCA) project was implemented in Cuamba District, Niassa Province to prevent and control cholera outbreaks through a preemptive cholera vaccination, strengthened surveillance system for cholera and diarrheal diseases, and better understanding of cholera-related healthcare seeking behavior of local populations, which may further guide the national cholera control and prevention strategies. This article presents the surveillance component of the MOCA project. METHODOLOGY/PRINCIPAL FINDINGS A prospective healthcare facility (HCF)-based surveillance of cholera and diarrheal disease was conducted in six HCFs in the District of Cuamba from March 2019 to December 2020. A systematic surveillance procedure has been put in place with capacity building in selected sentinel HCFs and a basic microbiology laboratory established on-site. Patients presenting with suspected cholera or other diarrheal symptoms were eligible for enrollment. Clinical data and rectal swab samples were collected for laboratory confirmation of Vibrio Cholerae and other pathogens. A total of 419 eligible patients from six HCFs were enrolled. The median age was 19.8 years with a similar age distribution between sentinel sites. The majority were patients who exhibited diarrhea symptoms not suspected of cholera (88.8%; n = 410). Among those, 59.2% (210/397) were female and 59.9% (235/392) were 15 years and above. There were 2 cholera cases, coming outside of the catchment area. The incidence of diarrheal diseases ranged from 40-103 per 100,000 population. No Vibrio cholerae was isolated among surveillance catchment population and Escherichia coli spp. (82/277; 29.6%) was the most common pathogen isolated. CONCLUSION/SIGNIFICANCE Efforts were made to strengthen the systematic surveillance of suspected cholera with standardised patient screening, enrolment, and diagnostics. The first basic microbiology laboratory in Niassa Province established in Cuamba District under the MOCA project needs to be integrated into the national network of laboratories for sustainability. No reports of laboratory confirmed cholera cases from the surveillance catchment area may be highly related to the pre-emptive oral cholera vaccine (OCV) mass vaccination campaign conducted in 2018 and the use of drugs by local populations prior to visiting the sentinel HCFs. Continued systematic cholera surveillance is needed to closely monitor the cholera endemicity and epidemics, and further evaluate the long-term impact of this vaccination. High incidence of diarrheal illnesses needs to be addressed with improved water, sanitation, and hygiene (WaSH) conditions in Cuamba District. Efforts integrated with the prioritization of prevention measures are fundamental for the control of cholera in the country.
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Affiliation(s)
| | | | | | | | | | - Ramos B. J. Mboane
- Provincial Health Directorate, Lichinga City, Niassa Province, Mozambique
| | - Sadate Assane
- Provincial Health Directorate, Lichinga City, Niassa Province, Mozambique
| | - Alide Omar
- District Health Directorate, Cuamba City, Cuamba District, Niassa Province, Mozambique
| | - Mariana Manso
- District Health Directorate, Cuamba City, Cuamba District, Niassa Province, Mozambique
| | | | - Naira Luiz
- Clinical, Assessment, Regulatory, Evaluation (CARE) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - David Mukasa
- Biostatistics and Data Management (BDM) Department, International Vaccine Institute, Seoul, Republic of Korea
| | - Geun Hyeog Jang
- Biostatistics and Data Management (BDM) Department, International Vaccine Institute, Seoul, Republic of Korea
| | - Ju Yeon Park
- Biostatistics and Data Management (BDM) Department, International Vaccine Institute, Seoul, Republic of Korea
| | - Florian Marks
- Epidemiology, Public Health, Impact (EPIC) Unit, International Vaccine Institute, Seoul, Republic of Korea
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ramzi Mraidi
- Biostatistics and Data Management (BDM) Department, International Vaccine Institute, Seoul, Republic of Korea
| | - Gi Deok Pak
- Biostatistics and Data Management (BDM) Department, International Vaccine Institute, Seoul, Republic of Korea
| | - Deok Ryun Kim
- Biostatistics and Data Management (BDM) Department, International Vaccine Institute, Seoul, Republic of Korea
| | - Se Eun Park
- Clinical, Assessment, Regulatory, Evaluation (CARE) Unit, International Vaccine Institute, Seoul, Republic of Korea
- Yonsei University Graduate School of Public Health, Seoul, Republic of Korea
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14
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Xu H, Zou K, Dent J, Wiens KE, Malembaka EB, Bwire G, Okitayemba PW, Hampton LM, Azman AS, Lee EC. Enhanced cholera surveillance to improve vaccination campaign efficiency. Nat Med 2024; 30:1104-1110. [PMID: 38443690 PMCID: PMC11031394 DOI: 10.1038/s41591-024-02852-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
Systematic testing for Vibrio cholerae O1 is rare, which means that the world's limited supply of oral cholera vaccines (OCVs) may not be delivered to areas with the highest true cholera burden. Here we used a phenomenological model with subnational geographic targeting and fine-scale vaccine effects to model how expanding V. cholerae testing affected impact and cost-effectiveness for preventive vaccination campaigns across different bacteriological confirmation and vaccine targeting assumptions in 35 African countries. Systematic testing followed by OCV targeting based on confirmed cholera yielded higher efficiency and cost-effectiveness and slightly fewer averted cases than status quo scenarios targeting suspected cholera. Targeting vaccine to populations with an annual incidence rate greater than 10 per 10,000, the testing scenario averted 10.8 (95% prediction interval (PI) 9.4-12.6) cases per 1,000 fully vaccinated persons while the status quo scenario averted 6.9 (95% PI 6.0-7.8) cases per 1,000 fully vaccinated persons. In the testing scenario, testing costs increased by US$31 (95% PI 25-39) while vaccination costs reduced by US$248 (95% PI 176-326) per averted case compared to the status quo. Introduction of systematic testing into cholera surveillance could improve efficiency and reach of global OCV supply for preventive vaccination.
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Affiliation(s)
- Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juan Dent
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kirsten E Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
- Makerere University School of Public Health, Kampala, Uganda
| | - Placide Welo Okitayemba
- Programme National d'Elimination de Choléra et lutte contre les autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of the Congo
| | | | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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15
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Xiao S, Abade A, Boru W, Kasambara W, Mwaba J, Ongole F, Mmanywa M, Trovão NS, Chilengi R, Kwenda G, Orach CG, Chibwe I, Bwire G, Stine OC, Milstone AM, Lessler J, Azman AS, Luo W, Murt K, Sack DA, Debes AK, Wohl S. New Vibrio cholerae sequences from Eastern and Southern Africa alter our understanding of regional cholera transmission. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.28.24302717. [PMID: 38585829 PMCID: PMC10996759 DOI: 10.1101/2024.03.28.24302717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Despite ongoing containment and vaccination efforts, cholera remains prevalent in many countries in sub-Saharan Africa. Part of the difficulty in containing cholera comes from our lack of understanding of how it circulates throughout the region. To better characterize regional transmission, we generated and analyzed 118 Vibrio cholerae genomes collected between 2007-2019 from five different countries in Southern and Eastern Africa. We showed that V. cholerae sequencing can be successful from a variety of sample types and filled in spatial and temporal gaps in our understanding of circulating lineages, including providing some of the first sequences from the 2018-2019 outbreaks in Uganda, Kenya, Tanzania, Zambia, and Malawi. Our results present a complex picture of cholera transmission in the region, with multiple lineages found to be co-circulating within several countries. We also find evidence that previously identified sporadic cases may be from larger, undersampled outbreaks, highlighting the need for careful examination of sampling biases and underscoring the need for continued and expanded cholera surveillance across the African continent.
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Affiliation(s)
- Shaoming Xiao
- Division of Pediatric Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmed Abade
- Ministry of Health, Dar es Salaam, Tanzania
- Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | - Waqo Boru
- Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | | | - John Mwaba
- Center for Infectious Disease Research, Zambia
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Roma Chilengi
- Zambia National Public Health Institute, Lusaka, Zambia
| | | | | | | | | | - O Colin Stine
- University of Maryland School of Medicine, Baltimore, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Wensheng Luo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kelsey Murt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shirlee Wohl
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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Kim JH, Tack B, Fiorino F, Pettini E, Marchello CS, Jacobs J, Crump JA, Marks F. Examining geospatial and temporal distribution of invasive non-typhoidal Salmonella disease occurrence in sub-Saharan Africa: a systematic review and modelling study. BMJ Open 2024; 14:e080501. [PMID: 38485477 PMCID: PMC10941155 DOI: 10.1136/bmjopen-2023-080501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/12/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Invasive non-typhoidal Salmonella (iNTS) disease is a significant health concern in sub-Saharan Africa. While our knowledge of a larger-scale variation is growing, understanding of the subnational variation in iNTS disease occurrence is lacking, yet crucial for targeted intervention. METHOD We performed a systematic review of reported occurrences of iNTS disease in sub-Saharan Africa, consulting literature from PubMed, Embase and Web of Science published since 2000. Eligibility for inclusion was not limited by study type but required that studies reported original data on human iNTS diseases based on the culture of a normally sterile site, specifying subnational locations and the year, and were available as full-text articles. We excluded studies that diagnosed iNTS disease based on clinical indications, cultures from non-sterile sites or serological testing. We estimated the probability of occurrence of iNTS disease for sub-Saharan Africa on 20 km × 20 km grids by exploring the association with geospatial covariates such as malaria, HIV, childhood growth failure, access to improved water, and sanitation using a boosted regression tree. RESULTS We identified 130 unique references reporting human iNTS disease in 21 countries published from 2000 through 2020. The estimated probability of iNTS occurrence grids showed significant spatial heterogeneity at all levels (20 km × 20 km grids, subnational, country and subregional levels) and temporal heterogeneity by year. For 2020, the probability of occurrence was higher in Middle Africa (0.34, 95% CI: 0.25 to 0.46), followed by Western Africa (0.33, 95% CI: 0.23 to 0.44), Eastern Africa (0.24, 95% CI: 0.17 to 0.33) and Southern Africa (0.08, 95% CI: 0.03 to 0.11). Temporal heterogeneity indicated that the probability of occurrence increased between 2000 and 2020 in countries such as the Republic of the Congo (0.05 to 0.59) and Democratic Republic of the Congo (0.10 to 0.48) whereas it decreased in countries such as Uganda (0.65 to 0.23) or Zimbabwe (0.61 to 0.37). CONCLUSION The iNTS disease occurrence varied greatly across sub-Saharan Africa, with certain regions being disproportionately affected. Exploring regions at high risk for iNTS disease, despite the limitations in our data, may inform focused resource allocation. This targeted approach may enhance efforts to combat iNTS disease in more affected areas.
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Affiliation(s)
- Jong-Hoon Kim
- International Vaccine Institute, Gwanak-gu, Seoul, Republic of Korea
| | - Bieke Tack
- Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Fabio Fiorino
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
- Department of Medicine and Surgery, LUM University "Giuseppe Degennaro", Bari, Italy
| | - Elena Pettini
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | | | - Jan Jacobs
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Florian Marks
- Epidemiology Unit, International Vaccine Institute, Seoul, Republic of Korea
- Department of Medicine, University of Cambridge, Cambridge, UK
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17
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Colston JM, Fang B, Houpt E, Chernyavskiy P, Swarup S, Gardner LM, Nong MK, Badr HS, Zaitchik BF, Lakshmi V, Kosek MN. The Planetary Child Health & Enterics Observatory (Plan-EO): A protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs. PLoS One 2024; 19:e0297775. [PMID: 38412156 PMCID: PMC10898779 DOI: 10.1371/journal.pone.0297775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 01/12/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments. METHODS The Planetary Child Health & Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants. DISCUSSION As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making and disseminating rigorously obtained, generalizable disease burden estimates. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available for download to the research and stakeholder communities. These can then be used as inputs to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection. STUDY REGISTRATION PROSPERO protocol #CRD42023384709.
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Affiliation(s)
- Josh M. Colston
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
| | - Bin Fang
- Department of Civil and Environmental Engineering, University of Virginia, Charlottesville, Virginia, United States of America
| | - Eric Houpt
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
| | - Pavel Chernyavskiy
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
| | - Samarth Swarup
- Biocomplexity Institute, University of Virginia, Charlottesville, Virginia, United States of America
| | - Lauren M. Gardner
- Department of Civil and Systems Engineering, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Malena K. Nong
- University of Virginia College of Arts & Sciences, Charlottesville, Virginia, United States of America
| | - Hamada S. Badr
- Department of Earth and Planetary Sciences, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Benjamin F. Zaitchik
- Department of Earth and Planetary Sciences, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Venkataraman Lakshmi
- Department of Civil and Environmental Engineering, University of Virginia, Charlottesville, Virginia, United States of America
| | - Margaret N. Kosek
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
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18
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Gilmour B, Wangdi K, Restrepo AC, Tsheten T, Kelly M, Clements A, Gray D, Lau C, Espino FE, Daga C, Mapalo V, Vaz Nery S, Bartlett A, Gebreyohannes EA, Alene KA. Protocol for spatial prediction of soil transmitted helminth prevalence in the Western Pacific region using a meta-analytical approach. Syst Rev 2024; 13:55. [PMID: 38321560 PMCID: PMC10845450 DOI: 10.1186/s13643-024-02469-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 01/25/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Soil transmitted helminth (STH) infections are estimated to impact 24% of the world's population and are responsible for chronic and debilitating morbidity. Disadvantaged communities are among the worst affected and are further marginalized as infection prevalence fuels the poverty cycle. Ambitious targets have been set to eliminate STH infections, but accurate epidemiological data will be required to inform appropriate interventions. This paper details the protocol for an analysis that aims to produce spatial prediction mapping of STH prevalence in the Western Pacific Region (WPR). METHODS The protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. The study design will combine the principles of systematic review, meta-analysis, and geospatial analysis. Systematic searches will be undertaken in PubMed, Scopus, ProQuest, Embase, and Web of Science for studies undertaken post 2000, to identify surveys that enable the prevalence of human STH infection within the WPR to be calculated. Covariate data for multivariable analysis will be obtained from publicly accessible sources. Survey data will be geolocated, and STH prevalence and covariates will be linked to produce a spatially referenced dataset for analysis. Bayesian model-based geostatistics will be used to generate spatially continuous estimates of STH prevalence mapped to a resolution of 1 km2. A separate geospatial model will be constructed for each STH species. Predictions of prevalence will be made for unsampled locations and maps will be overlaid for each STH species to obtain co-endemicity maps. DISCUSSION This protocol facilitates study replication and may be applied to other infectious diseases or alternate geographies. Results of the subsequent analysis will identify geographies with high STH prevalence's and can be used to inform resource allocation in combating this neglected tropical disease. TRIAL REGISTRATION Open Science Framework: osf.io/qmxcj.
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Affiliation(s)
- Beth Gilmour
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent St, Bentley WA, Western Australia, 6102, Australia.
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, West Perth, Western Australia, Australia.
| | | | | | | | | | - Archie Clements
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, West Perth, Western Australia, Australia
- Queen's University, Belfast, Northern Ireland
| | - Darren Gray
- Australia National University, Canberra, Australia
| | - Colleen Lau
- The University of Queensland, Brisbane, Australia
| | | | - Chona Daga
- Research Institute for Tropical Medicine, Muntinlupa, Philippines
| | - Vanessa Mapalo
- Research Institute for Tropical Medicine, Muntinlupa, Philippines
| | - Susana Vaz Nery
- The Kirby Institute, University of New South Wales, Kensington, Australia
| | - Adam Bartlett
- The Kirby Institute, University of New South Wales, Kensington, Australia
| | | | - Kefyalew Addis Alene
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent St, Bentley WA, Western Australia, 6102, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, West Perth, Western Australia, Australia
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19
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Kim JH, Choi J, Kim C, Pak GD, Parajulee P, Haselbeck A, Park SE, Mogasale V, Jeon HJ, Browne AJ, Owusu-Dabo E, Rakotozandrindrainy R, Bassiahi AS, Teferi M, Lunguya-Metila O, Dolecek C, Pitzer VE, Crump JA, Hay SI, Marks F. Mapping the incidence rate of typhoid fever in sub-Saharan Africa. PLoS Negl Trop Dis 2024; 18:e0011902. [PMID: 38408128 DOI: 10.1371/journal.pntd.0011902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 03/26/2024] [Accepted: 01/04/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND With more than 1.2 million illnesses and 29,000 deaths in sub-Saharan Africa in 2017, typhoid fever continues to be a major public health problem. Effective control of the disease would benefit from an understanding of the subnational geospatial distribution of the disease incidence. METHOD We collated records of the incidence rate of typhoid fever confirmed by culture of blood in Africa from 2000 to 2022. We estimated the typhoid incidence rate for sub-Saharan Africa on 20 km × 20 km grids by exploring the association with geospatial covariates representing access to improved water and sanitation, health conditions of the population, and environmental conditions. RESULTS We identified six published articles and one pre-print representing incidence rate estimates in 22 sites in 2000-2022. Estimated incidence rates showed geospatial variation at sub-national, national, and regional levels. The incidence rate was high in Western and Eastern African subregions followed by Southern and Middle African subregions. By age, the incidence rate was highest among 5-14 yo followed by 2-4 yo, > 14 yo, and 0-1 yo. When aggregated across all age classes and grids that comprise each country, predicted incidence rates ranged from 43.7 (95% confidence interval: 0.6 to 591.2) in Zimbabwe to 2,957.8 (95% CI: 20.8 to 4,245.2) in South Sudan per 100,000 person-years. Sub-national heterogeneity was evident with the coefficient of variation at the 20 km × 20 km grid-level ranging from 0.7 to 3.3 and was generally lower in high-incidence countries and widely varying in low-incidence countries. CONCLUSION Our study provides estimates of 20 km × 20 km incidence rate of typhoid fever across sub-Saharan Africa based on data collected from 2000 through 2020. Increased understanding of the subnational geospatial variation of typhoid fever in Africa may inform more effective intervention programs by better targeting resources to heterogeneously disturbed disease risk.
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Affiliation(s)
- Jong-Hoon Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jungsoon Choi
- Department of Mathematics, Hanyang University, Seoul, Republic of Korea
| | - Chaelin Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | - Gi Deok Pak
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | - Se Eun Park
- International Vaccine Institute, Seoul, Republic of Korea
- Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
| | | | - Hyon Jin Jeon
- International Vaccine Institute, Seoul, Republic of Korea
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Madagascar Institute for Vaccine Research, University of Antananarivo, Antananarivo, Madagascar
| | - Annie J Browne
- Malaria Atlas Project, Telethon Kids Institute, Perth, Australia
| | - Ellis Owusu-Dabo
- Malaria Atlas Project, Telethon Kids Institute, Perth, Australia
| | - Raphaël Rakotozandrindrainy
- School of Public Health, Kwame Nkrumah University of Science and Technology, Laing Building Complex J.W. Acheampong CI, Kumasi, Ghana
| | | | - Mekonnen Teferi
- Armauer Hansen Research Institute, ALERT Compound Zenebework, Addis Ababa, Ethiopia
| | - Octavie Lunguya-Metila
- Department of Microbiology, Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
- Department of Medical Biology, Microbiology Service, University Teaching Hospital, Ave De L'hopital, Kinshasa, Democratic Republic of the Congo
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Virginia E Pitzer
- Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
- Yale Institute for Global Health, New Haven, Connecticut, United States of America
| | - John A Crump
- Centre for International Health, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Simon I Hay
- Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, Washington, United States of America
- Department of Health Metrics Sciences, University of Washington, Seattle, Washington, United States of America
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
- School of Public Health, Kwame Nkrumah University of Science and Technology, Laing Building Complex J.W. Acheampong CI, Kumasi, Ghana
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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20
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Colston JM, Chernyavskiy P, Gardner L, Nong M, Fang B, Houpt E, Swarup S, Badr H, Zaitchik B, Lakshmi V, Kosek M. The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs. RESEARCH SQUARE 2024:rs.3.rs-2640564. [PMID: 36993232 PMCID: PMC10055683 DOI: 10.21203/rs.3.rs-2640564/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Background Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments. Methods The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants. Discussion As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection. Study registration PROSPERO protocol #CRD42023384709.
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Affiliation(s)
| | | | | | - Malena Nong
- University of Virginia College of Arts & Sciences
| | | | - Eric Houpt
- University of Virginia School of Medicine
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21
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Colston JM, Chernyavskiy P, Gardner L, Nong M, Fang B, Houpt E, Swarup S, Badr H, Zaitchik B, Lakshmi V, Kosek M. The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs. RESEARCH SQUARE 2024:rs.3.rs-2640564. [PMID: 36993232 PMCID: PMC10055683 DOI: 10.21203/rs.3.rs-2640564/v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments. Methods The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants. Discussion As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection. Study registration PROSPERO protocol #CRD42023384709.
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Affiliation(s)
| | | | | | - Malena Nong
- University of Virginia College of Arts & Sciences
| | | | - Eric Houpt
- University of Virginia School of Medicine
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Endres K, Mwishingo A, Thomas E, Boroto R, Ntumba Nyarukanyi W, Bisimwa JC, Sanvura P, Perin J, Bengehya J, Maheshe G, Cikomola C, George CM. A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 21:27. [PMID: 38248491 PMCID: PMC10815631 DOI: 10.3390/ijerph21010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/30/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024]
Abstract
Individuals living near cholera patients have an increased risk of cholera infections. Case-area targeted interventions (CATIs) promoting improved water, sanitation, and hygiene (WASH) present a promising approach to reducing cholera for those residing near cholera cases. However, there is limited evidence on the effectiveness and implementation of this approach in increasing WASH behaviors. We conducted a mixed-methods program evaluation in rural and urban eastern Democratic Republic of the Congo. The quantitative component included household structured observations and spot checks in CATI and control areas to assess WASH conditions and behaviors. The qualitative component included semi-structured interviews with CATI recipients, non-recipients, and implementers to assess CATI implementation. A total of 399 participants were enrolled in the quantitative evaluation conducted within 1 month of CATI delivery. For the qualitative evaluation, 41 semi-structured interviews were conducted, 30 with individuals in CATI areas (recipients and non-recipients) and 11 with CATI implementers. Handwashing with soap was low among both CATI and control area participants (1% vs. 2%, p = 0.89). Significantly more CATI area households (75%) had chlorine tablets present compared to control area households (0%) (p < 0.0001); however, the percentage of households with stored water free chlorine concentrations > 0.2 mg/L was low for both CATI and control area households (11% vs. 6%, p = 0.45). Implementers reported an insufficient supply of soap for distribution to recipients and mistrust in the community of their activities. CATI recipients demonstrated low knowledge of the correct preparation and use of chlorine for water treatment. Recipients also indicated a need for CATI implementers to engage community leaders. As CATIs are part of cholera control plans in many cholera-endemic countries, it is important to evaluate existing programs and develop evidence-based approaches to deliver CATIs that are both tailored to the local context and engage affected communities to increase WASH behaviors to reduce the spread of cholera.
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Affiliation(s)
- Kelly Endres
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
| | - Alain Mwishingo
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Elizabeth Thomas
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
| | - Raissa Boroto
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Wivine Ntumba Nyarukanyi
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Jean-Claude Bisimwa
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Presence Sanvura
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
| | - Jamie Perin
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
| | - Justin Bengehya
- Bureau de l’Information Sanitaire, Surveillance Epidémiologique et Recherche Scientifique Division Provinciale de la Santé/Sud Kivu, Ministère de la Santé Publique, Hygiène et Prévention, Bukavu B.P 1899, Democratic Republic of the Congo;
| | - Ghislain Maheshe
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo;
| | - Cirhuza Cikomola
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo; (A.M.); (R.B.); (W.N.N.); (J.-C.B.); (P.S.); (C.C.)
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo;
| | - Christine Marie George
- Department of International Health, Program in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (K.E.); (E.T.); (J.P.)
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Ngingo BL, Mchome ZS, Bwana VM, Chengula A, Mwanyika G, Mremi I, Sindato C, Mboera LEG. Socioecological systems analysis of potential factors for cholera outbreaks and assessment of health system's readiness to detect and respond in Ilemela and Nkasi districts, Tanzania. BMC Health Serv Res 2023; 23:1261. [PMID: 37968626 PMCID: PMC10652585 DOI: 10.1186/s12913-023-10263-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 11/01/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Cholera outbreaks are a recurrent issue in Tanzania, with Ilemela and Nkasi districts being particulary affected. The objective of this study was to conduct a socio-ecological system (SES) analysis of cholera outbreaks in these districts, identifying potential factors and assessing the preparedness for cholera prevention and control. METHODS A cross-sectional study was carried out in Ilemela and Nkasi districts of Mwanza and Rukwa regions, respectively in Tanzania between September and October 2021. A SES framework analysis was applied to identify potential factors associated with cholera outbreaks and assess the readiness of the districts to cholera prevention and control. RESULTS Ilemela is characterised by urban and peri-urban ecosystems while Nkasi is mainly rural. Cholera was reported to disproportionately affect people living along the shores of Lake Victoria in Ilemela and Lake Tanganyika in Nkasi, particularly fishermen and women involved infish trading. The main potential factors identified for cholera outbreaks included defecation in the shallow ends and along the edges of lakes, open defecation, bathing/swimming in contaminated waters and improper waste disposal. The preparedness of both districts for cholera prevention and response was found to be inadequate due to limited laboratory capacity, insufficient human resources, and budget constraints. CONCLUSION People of Ilemela and Nkasi districts remain at significant risk of recurrent cholera outbreaks and the capacity of the districts to detect the disease is limited. Urgent preventive measures, such as conducting considerable community awareness campaigns on personal hygiene and environmental sanitation are needed to alleviate the disease burden and reduce future cholera outbreaks.
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Affiliation(s)
- Baraka L Ngingo
- Department of Applied Sciences, Mbeya University of Science and Technology, Mbeya, Tanzania.
| | - Zaina S Mchome
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Veneranda M Bwana
- National Institute for Medical Research, Amani Research Centre, Muheza, Tanzania
| | - Augustino Chengula
- Department of Microbiology, Parasitology and Biotechnology, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Gaspary Mwanyika
- Department of Applied Sciences, Mbeya University of Science and Technology, Mbeya, Tanzania
| | - Irene Mremi
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Calvin Sindato
- National Institute for Medical Research, Tabora Research Centre, Tabora, Tanzania
| | - Leonard E G Mboera
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania
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Mavhungu M, Digban TO, Nwodo UU. Incidence and Virulence Factor Profiling of Vibrio Species: A Study on Hospital and Community Wastewater Effluents. Microorganisms 2023; 11:2449. [PMID: 37894107 PMCID: PMC10609040 DOI: 10.3390/microorganisms11102449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
This study aimed to determine the incidence and virulence factor profiling of Vibrio species from hospital wastewater (HWW) and community wastewater effluents. Wastewater samples from selected sites were collected, processed, and analysed presumptively by the culture dependent methods and molecular techniques. A total of 270 isolates were confirmed as Vibrio genus delineating into V. cholerae (27%), V. parahaemolyticus (9.1%), V. vulnificus (4.1%), and V. fluvialis (3%). The remainder (>50%) may account for other Vibrio species not identified in the study. The four Vibrio species were isolated from secondary hospital wastewater effluent (SHWE), while V. cholerae was the sole specie isolated from Limbede community wastewater effluent (LCWE) and none of the four Vibrio species was recovered from tertiary hospital wastewater effluent (THWE). However, several virulence genes were identified among V. cholerae isolates from SHWE: ToxR (88%), hylA (81%), tcpA (64%), VPI (58%), ctx (44%), and ompU (34%). Virulence genes factors among V. cholerae isolates from LCWE were: ToxR (78%), ctx (67%), tcpA (44%), and hylA (44%). Two different genes (vfh and hupO) were identified in all confirmed V. fluvialis isolates. Among V. vulnificus, vcgA (50%) and vcgB (67%) were detected. In V. parahaemolyticus, tdh (56%) and tlh (100%) were also identified. This finding reveals that the studied aquatic niches pose serious potential health risk with Vibrio species harbouring virulence signatures. The distribution of virulence genes is valuable for ecological site quality, as well as epidemiological marker in the control and management of diseases caused by Vibrio species. Regular monitoring of HWW and communal wastewater effluent would allow relevant establishments to forecast, detect, and mitigate any public health threats in advance.
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Affiliation(s)
- Mashudu Mavhungu
- Patho-Biocatalysis Group, Department of Biochemistry and Microbiology, University of Fort Hare, Private Bag X1314, Alice 5700, South Africa (T.O.D.)
- Department of Biochemistry and Microbiology, University of Fort Hare, Alice 5700, South Africa
| | - Tennison O. Digban
- Patho-Biocatalysis Group, Department of Biochemistry and Microbiology, University of Fort Hare, Private Bag X1314, Alice 5700, South Africa (T.O.D.)
- Department of Biochemistry and Microbiology, University of Fort Hare, Alice 5700, South Africa
| | - Uchechukwu U. Nwodo
- Patho-Biocatalysis Group, Department of Biochemistry and Microbiology, University of Fort Hare, Private Bag X1314, Alice 5700, South Africa (T.O.D.)
- Department of Biochemistry and Microbiology, University of Fort Hare, Alice 5700, South Africa
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Wiens KE, Xu H, Zou K, Mwaba J, Lessler J, Malembaka EB, Demby MN, Bwire G, Qadri F, Lee EC, Azman AS. Estimating the proportion of clinically suspected cholera cases that are true Vibrio cholerae infections: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004286. [PMID: 37708235 PMCID: PMC10538743 DOI: 10.1371/journal.pmed.1004286] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 09/28/2023] [Accepted: 08/25/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Cholera surveillance relies on clinical diagnosis of acute watery diarrhea. Suspected cholera case definitions have high sensitivity but low specificity, challenging our ability to characterize cholera burden and epidemiology. Our objective was to estimate the proportion of clinically suspected cholera that are true Vibrio cholerae infections and identify factors that explain variation in positivity. METHODS AND FINDINGS We conducted a systematic review of studies that tested ≥10 suspected cholera cases for V. cholerae O1/O139 using culture, PCR, and/or a rapid diagnostic test. We searched PubMed, Embase, Scopus, and Google Scholar for studies that sampled at least one suspected case between January 1, 2000 and April 19, 2023, to reflect contemporary patterns in V. cholerae positivity. We estimated diagnostic test sensitivity and specificity using a latent class meta-analysis. We estimated V. cholerae positivity using a random-effects meta-analysis, adjusting for test performance. We included 119 studies from 30 countries. V. cholerae positivity was lower in studies with representative sampling and in studies that set minimum ages in suspected case definitions. After adjusting for test performance, on average, 52% (95% credible interval (CrI): 24%, 80%) of suspected cases represented true V. cholerae infections. After adjusting for test performance and study methodology, the odds of a suspected case having a true infection were 5.71 (odds ratio 95% CrI: 1.53, 15.43) times higher when surveillance was initiated in response to an outbreak than in non-outbreak settings. Variation across studies was high, and a limitation of our approach was that we were unable to explain all the heterogeneity with study-level attributes, including diagnostic test used, setting, and case definitions. CONCLUSIONS In this study, we found that burden estimates based on suspected cases alone may overestimate the incidence of medically attended cholera by 2-fold. However, accounting for cases missed by traditional clinical surveillance is key to unbiased cholera burden estimates. Given the substantial variability in positivity between settings, extrapolations from suspected to confirmed cases, which is necessary to estimate cholera incidence rates without exhaustive testing, should be based on local data.
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Affiliation(s)
- Kirsten E. Wiens
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology and Biostatistics, College of Public Health, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Hanmeng Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kaiyue Zou
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John Mwaba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Maya N. Demby
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Godfrey Bwire
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Elizabeth C. Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
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26
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Kayembe HC, Bompangue D, Linard C, Mandja BA, Batumbo D, Matunga M, Muwonga J, Moutschen M, Situakibanza H, Ozer P. Drivers of the dynamics of the spread of cholera in the Democratic Republic of the Congo, 2000-2018: An eco-epidemiological study. PLoS Negl Trop Dis 2023; 17:e0011597. [PMID: 37639440 PMCID: PMC10491302 DOI: 10.1371/journal.pntd.0011597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 09/08/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The dynamics of the spread of cholera epidemics in the Democratic Republic of the Congo (DRC), from east to west and within western DRC, have been extensively studied. However, the drivers of these spread processes remain unclear. We therefore sought to better understand the factors associated with these spread dynamics and their potential underlying mechanisms. METHODS In this eco-epidemiological study, we focused on the spread processes of cholera epidemics originating from the shores of Lake Kivu, involving the areas bordering Lake Kivu, the areas surrounding the lake areas, and the areas out of endemic eastern DRC (eastern and western non-endemic provinces). Over the period 2000-2018, we collected data on suspected cholera cases, and a set of several variables including types of conflicts, the number of internally displaced persons (IDPs), population density, transportation network density, and accessibility indicators. Using multivariate ordinal logistic regression models, we identified factors associated with the spread of cholera outside the endemic eastern DRC. We performed multivariate Vector Auto Regressive models to analyze potential underlying mechanisms involving the factors associated with these spread dynamics. Finally, we classified the affected health zones using hierarchical ascendant classification based on principal component analysis (PCA). FINDINGS The increase in the number of suspected cholera cases, the exacerbation of conflict events, and the number of IDPs in eastern endemic areas were associated with an increased risk of cholera spreading outside the endemic eastern provinces. We found that the increase in suspected cholera cases was influenced by the increase in battles at lag of 4 weeks, which were influenced by the violence against civilians with a 1-week lag. The violent conflict events influenced the increase in the number of IDPs 4 to 6 weeks later. Other influences and uni- or bidirectional causal links were observed between violent and non-violent conflicts, and between conflicts and IDPs. Hierarchical clustering on PCA identified three categories of affected health zones: densely populated urban areas with few but large and longer epidemics; moderately and accessible areas with more but small epidemics; less populated and less accessible areas with more and larger epidemics. CONCLUSION Our findings argue for monitoring conflict dynamics to predict the risk of geographic expansion of cholera in the DRC. They also suggest areas where interventions should be appropriately focused to build their resilience to the disease.
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Affiliation(s)
- Harry César Kayembe
- Department of Basic Sciences, Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
- Department of Environmental Sciences and Management, UR SPHERES, Faculty of Sciences, Université de Liège, Arlon, Belgium
| | - Didier Bompangue
- Department of Basic Sciences, Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
- Chrono-Environnement, UMR CNRS 6249, Université de Franche-Comté, Besançon, France
| | | | - Bien-Aimé Mandja
- Department of Basic Sciences, Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Doudou Batumbo
- Department of Basic Sciences, Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Muriel Matunga
- Graduate School Public Health Department, Adventist International Institute of Advanced Studies, Silang, Cavite, Philippines
| | - Jérémie Muwonga
- Department of Medical Biology, Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Michel Moutschen
- Department of Clinical Sciences, Immunopathology—Infectious Diseases and General Internal Medicine, Université de Liège, Liege, Belgium
| | - Hippolyte Situakibanza
- Department of Internal Medicine, Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
- Department of Parasitology and Tropical Medicine, Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Pierre Ozer
- Department of Environmental Sciences and Management, UR SPHERES, Faculty of Sciences, Université de Liège, Arlon, Belgium
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Jobe NB, Huijben S, Paaijmans KP. Non-target effects of chemical malaria vector control on other biological and mechanical infectious disease vectors. Lancet Planet Health 2023; 7:e706-e717. [PMID: 37558351 DOI: 10.1016/s2542-5196(23)00136-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 06/09/2023] [Accepted: 06/17/2023] [Indexed: 08/11/2023]
Abstract
Public health insecticides play a crucial role in malaria control and elimination programmes. Many other arthropods, including mechanical and biological vectors of infectious diseases, have similar indoor feeding or resting behaviours, or both, as malaria mosquitoes, and could be exposed to the same insecticides. In this Personal View, we show that little is known about the insecticide susceptibility status and the extent of exposure to malaria interventions of other arthropod species. We highlight that there is an urgent need to better understand the selection pressure for insecticide resistance in those vectors, to ensure current and future active ingredients remain effective in targeting a broad range of arthropod species, allowing us to prevent and control future outbreaks of infectious diseases other than malaria.
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Affiliation(s)
- Ndey Bassin Jobe
- The Center for Evolution & Medicine, School of Life Sciences, Arizona State University, Tempe, AZ, USA
| | - Silvie Huijben
- The Center for Evolution & Medicine, School of Life Sciences, Arizona State University, Tempe, AZ, USA; Simon A Levin Mathematical, Computational and Modeling Sciences Center, Arizona State University, Tempe, AZ, USA
| | - Krijn P Paaijmans
- The Center for Evolution & Medicine, School of Life Sciences, Arizona State University, Tempe, AZ, USA; Simon A Levin Mathematical, Computational and Modeling Sciences Center, Arizona State University, Tempe, AZ, USA; The Biodesign Center for Immunotherapy, Vaccines and Virotherapy, Arizona State University, Tempe, AZ, USA; ISGlobal, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.
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28
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Amshi AH, Prasad R. Time series analysis and forecasting of cholera disease using discrete wavelet transform and seasonal autoregressive integrated moving average model. SCIENTIFIC AFRICAN 2023. [DOI: 10.1016/j.sciaf.2023.e01652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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Tuson M, Yap M, Whyatt D. Investigating local variation in disease rates within high-rate regions identified using smoothing. GEOSPATIAL HEALTH 2023; 18. [PMID: 37246547 DOI: 10.4081/gh.2023.1144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/20/2023] [Indexed: 05/30/2023]
Abstract
Exploratory disease maps are designed to identify risk factors of disease and guide appropriate responses to disease and helpseeking behaviour. However, when produced using aggregatelevel administrative units, as is standard practice, disease maps may mislead users due to the Modifiable Areal Unit Problem (MAUP). Smoothed maps of fine-resolution data mitigate the MAUP but may still obscure spatial patterns and features. To investigate these issues, we mapped rates of Mental Health- Related Emergency Department (MHED) presentations in Perth, Western Australia, in 2018/19 using Australian Bureau of Statistics (ABS) Statistical Areas Level 2 (SA2) boundaries and a recent spatial smoothing technique: the Overlay Aggregation Method (OAM). Then, we investigated local variation in rates within high-rate regions delineated using both approaches. The SA2- and OAM-based maps identified two and five high-rate regions, respectively, with the latter not conforming to SA2 boundaries. Meanwhile, both sets of high-rate regions were found to comprise a select number of localised areas with exceptionally high rates. These results demonstrate how, due to the MAUP, disease maps that are produced using aggregate-level administrative units are unreliable as a basis for delineating geographic regions of interest for targeted interventions. Instead, reliance on such maps to guide responses may compromise the efficient and equitable delivery of healthcare. Detailed investigation of local variation in rates within high-rate regions identified using both administrative units and smoothing is required to improve hypothesis generation and the design of healthcare responses.
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Affiliation(s)
- Matthew Tuson
- School of Physics, Mathematics and Computing, University of Western Australia, Perth, Western Australia; Medical School, University of Western Australia, Perth, Western Australia.
| | - Matthew Yap
- Medical School, University of Western Australia, Perth, Western Australia.
| | - David Whyatt
- Medical School, University of Western Australia, Perth, Western Australia.
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30
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Boru W, Xiao S, Amoth P, Kareko D, Langat D, Were I, Ali M, Sack DA, Lee EC, Debes AK. Prioritizing interventions for cholera control in Kenya, 2015-2020. PLoS Negl Trop Dis 2023; 17:e0010928. [PMID: 37196011 PMCID: PMC10228803 DOI: 10.1371/journal.pntd.0010928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 05/30/2023] [Accepted: 04/20/2023] [Indexed: 05/19/2023] Open
Abstract
Kenya has experienced cholera outbreaks since 1971, with the most recent wave beginning in late 2014. Between 2015-2020, 32 of 47 counties reported 30,431 suspected cholera cases. The Global Task Force for Cholera Control (GTFCC) developed a Global Roadmap for Ending Cholera by 2030, which emphasizes the need to target multi-sectoral interventions in priority cholera burden hotspots. This study utilizes the GTFCC's hotspot method to identify hotspots in Kenya at the county and sub-county administrative levels from 2015 through 2020. 32 of 47 (68.1%) counties reported cholera cases during this time while only 149 of 301 (49.5%) sub-counties reported cholera cases. The analysis identifies hotspots based on the mean annual incidence (MAI) over the past five-year period and cholera's persistence in the area. Applying a MAI threshold of 90th percentile and the median persistence at both the county and sub-county levels, we identified 13 high risk sub-counties from 8 counties, including the 3 high risk counties of Garissa, Tana River and Wajir. This demonstrates that several sub-counties are high level hotspots while their counties are not. In addition, when cases reported by county versus sub-county hotspot risk are compared, 1.4 million people overlapped in the areas identified as both high-risk county and high-risk sub-county. However, assuming that finer scale data is more accurate, 1.6 million high risk sub-county people would have been misclassified as medium risk with a county-level analysis. Furthermore, an additional 1.6 million people would have been classified as living in high-risk in a county-level analysis when at the sub-county level, they were medium, low or no-risk sub-counties. This results in 3.2 million people being misclassified when county level analysis is utilized rather than a more-focused sub-county level analysis. This analysis highlights the need for more localized risk analyses to target cholera intervention and prevention efforts towards the populations most vulnerable.
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Affiliation(s)
- Waqo Boru
- Ministry of Health, Nairobi, Kenya
- Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | - Shaoming Xiao
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | | | | | | | - Ian Were
- Ministry of Health, Nairobi, Kenya
| | - Mohammad Ali
- Johns Hopkins School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
| | - David A. Sack
- Johns Hopkins School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
| | - Elizabeth C. Lee
- Johns Hopkins School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
| | - Amanda K. Debes
- Johns Hopkins School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
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31
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Feinmann J. Cholera makes a comeback amid calls to boost vaccine production. BMJ 2023; 380:636. [PMID: 36990501 DOI: 10.1136/bmj.p636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Khan AI, Islam MT, Amin MA, Khan ZH, Qadri F. Outbreak of diarrheal diseases causes mortality in different geographical locations of Bangladesh during the 2021 COVID-19 era. Front Public Health 2023; 11:1103518. [PMID: 36778536 PMCID: PMC9911683 DOI: 10.3389/fpubh.2023.1103518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023] Open
Abstract
Objectives Diarrhea is a major public health problem in low- and middle-income countries, including Bangladesh. Of the different spectrums of diarrheal diseases, cholera occurs every year, causing outbreaks and epidemics following a biannual seasonal pattern. Due to the COVID-19 pandemic, hospitalization for diarrheal diseases decreased in 2020 compared to the previous years. However, in 2021, massive outbreaks occurred in different geographical locations of the country. We described that an outbreak of diarrheal diseases causes mortality in different geographical locations in Bangladesh. Method In this study, we present a report of diarrhea outbreaks that were reported in 2018-2021 in different parts of Bangladesh, and data have been captured from different sources such as print and electronic media as well as from a nationwide surveillance system. Results Among these locations, districts of Barisal Division, Kishorganj, Noakhali, Gopalganj, Bandarban, and Chattogram were the major hotspots of the outbreaks where high morbidity due to acute watery diarrhea and even mortality, which is usually low in Bangladesh, were recorded. Conclusion Early detection and prevention and strengthening of the surveillance system are needed to combat the diarrheal upsurge, take immediate control, and adopt preventive strategies.
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Affiliation(s)
- Ashraful Islam Khan
- 1International Centre for Diarrhoeal Disease Research, icddr, b, Dhaka, Bangladesh,*Correspondence: Ashraful Islam Khan ✉
| | - Md. Taufiqul Islam
- 1International Centre for Diarrhoeal Disease Research, icddr, b, Dhaka, Bangladesh,2School of Medical Science, Griffith University, Gold Coast, QLD, Australia
| | | | - Zahid Hasan Khan
- 1International Centre for Diarrhoeal Disease Research, icddr, b, Dhaka, Bangladesh
| | - Firdausi Qadri
- 1International Centre for Diarrhoeal Disease Research, icddr, b, Dhaka, Bangladesh
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Madullu MT, Thomas DSK, Nyanza EC, Seni J, Ngallaba SE, Kiluvia S, Asori M, Kangmennaang J. Spatial distribution of suspected and confirmed cholera cases in Mwanza City, Northern Tanzania. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001261. [PMID: 36962896 PMCID: PMC10022096 DOI: 10.1371/journal.pgph.0001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/06/2022] [Indexed: 01/09/2023]
Abstract
Cholera, which is caused by Vibrio cholerae, persists as a devastating acute diarrheal disease. Despite availability of information on socio-cultural, agent and hosts risk factors, the disease continues to claim lives of people in Tanzania. The present study explores spatial patterns of cholera cases during a 2015-16 outbreak in Mwanza, Tanzania using a geographical information system (GIS) to identify concentrations of cholera cases. This cross-sectional study was conducted in Ilemela and Nyamagana Districts, Mwanza City. The two-phase data collection included: 1) retrospectively reviewing and capturing 852 suspected cholera cases from clinical files during the outbreak between August, 2015, and April, 2016, and 2) mapping of residence of suspected and confirmed cholera cases using global positioning systems (GPS). A majority of cholera patients were from Ilemela District (546, 64.1%), were males (506, 59.4%) and their median age was 27 (19-36) years. Of the 452 (55.1%) laboratory tests, 352 (77.9%) were confirmed to have Vibrio cholerae infection. Seven patients (0.80%) died. Cholera cases clustered in certain areas of Mwanza City. Sangabuye, Bugogwa and Igoma Wards had the largest number of confirmed cholera cases, while Luchelele Ward had no reported cholera cases. Concentrations may reflect health-seeking behavior as much as disease distribution. Topographical terrain, untreated water, physical and built environment, and health-seeking behaviors play a role in cholera epidemic in Mwanza City. The spatial analysis suggests patterns of health-seeking behavior more than patterns of disease. Maps similar to those generated in this study would be an important future resource for identifying an impending cholera outbreak in real-time to coordinate community members, community leaders and health personnel for guiding targeted education, outreach, and interventions.
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Affiliation(s)
- Monica T Madullu
- Department of Environmental, Occupational and Research GIS, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Deborah S K Thomas
- Department of Geography and Earth Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States of America
| | - Elias C Nyanza
- Department of Environmental, Occupational and Research GIS, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Jeremiah Seni
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Sospatro E Ngallaba
- Department of Environmental, Occupational and Research GIS, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Sophia Kiluvia
- Environmental Health Department, Mwanza City Council, Mwanza, Tanzania
| | - Moses Asori
- Department of Geography and Earth Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States of America
| | - Joseph Kangmennaang
- School of Kinesiology and Health Studies, Queens University, Kingston Ontario, Canada
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Hounmanou YMG, Njamkepo E, Rauzier J, Gallandat K, Jeandron A, Kamwiziku G, Porten K, Luquero F, Abedi AA, Rumedeka BB, Miwanda B, Michael M, Okitayemba PW, Saidi JM, Piarroux R, Weill FX, Dalsgaard A, Quilici ML. Genomic Microevolution of Vibrio cholerae O1, Lake Tanganyika Basin, Africa. Emerg Infect Dis 2023; 29:149-153. [PMID: 36573719 PMCID: PMC9796204 DOI: 10.3201/eid2901.220641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Africa's Lake Tanganyika basin is a cholera hotspot. During 2001-2020, Vibrio cholerae O1 isolates obtained from the Democratic Republic of the Congo side of the lake belonged to 2 of the 5 clades of the AFR10 sublineage. One clade became predominant after acquiring a parC mutation that decreased susceptibility to ciprofloxacin.
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35
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Jones FK, Bhuiyan TR, Muise RE, Khan AI, Slater DM, Hutt Vater KR, Chowdhury F, Kelly M, Xu P, Kováč P, Biswas R, Kamruzzaman M, Ryan ET, Calderwood SB, LaRocque RC, Lessler J, Charles RC, Leung DT, Qadri F, Harris JB, Azman AS. Identifying Recent Cholera Infections Using a Multiplex Bead Serological Assay. mBio 2022; 13:e0190022. [PMID: 36286520 PMCID: PMC9765614 DOI: 10.1128/mbio.01900-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/31/2022] [Indexed: 11/20/2022] Open
Abstract
Estimates of incidence based on medically attended cholera can be severely biased. Vibrio cholerae O1 leaves a lasting antibody signal and recent advances showed that these can be used to estimate infection incidence rates from cross-sectional serologic data. Current laboratory methods are resource intensive and challenging to standardize across laboratories. A multiplex bead assay (MBA) could efficiently expand the breadth of measured antibody responses and improve seroincidence accuracy. We tested 305 serum samples from confirmed cholera cases (4 to 1083 d postinfection) and uninfected contacts in Bangladesh using an MBA (IgG/IgA/IgM for 7 Vibrio cholerae O1-specific antigens) as well as traditional vibriocidal and enzyme-linked immunosorbent assays (2 antigens, IgG, and IgA). While postinfection vibriocidal responses were larger than other markers, several MBA-measured antibodies demonstrated robust responses with similar half-lives. Random forest models combining all MBA antibody measures allowed for accurate identification of recent cholera infections (e.g., past 200 days) including a cross-validated area under the curve (cvAUC200) of 92%, with simpler 3 IgG antibody models having similar accuracy. Across infection windows between 45 and 300 days, the accuracy of models trained on MBA measurements was non-inferior to models based on traditional assays. Our results illustrated a scalable cholera serosurveillance tool that can be incorporated into multipathogen serosurveillance platforms. IMPORTANCE Reliable estimates of cholera incidence are challenged by poor clinical surveillance and health-seeking behavior biases. We showed that cross-sectional serologic profiles measured with a high-throughput multiplex bead assay can lead to accurate identification of those infected with pandemic Vibrio cholerae O1, thus allowing for estimates of seroincidence. This provides a new avenue for understanding the epidemiology of cholera, identifying priority areas for cholera prevention/control investments, and tracking progress in the global fight against this ancient disease.
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Affiliation(s)
- Forrest K. Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Taufiqur R. Bhuiyan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rachel E. Muise
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashraful I. Khan
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Damien M. Slater
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kian Robert Hutt Vater
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fahima Chowdhury
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Meagan Kelly
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peng Xu
- Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Pavol Kováč
- Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Rajib Biswas
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Kamruzzaman
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Edward T. Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stephen B. Calderwood
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Regina C. LaRocque
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
- University of North Carolina Population Center, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Richelle C. Charles
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Daniel T. Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Microbiology and Immunology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Firdausi Qadri
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Jason B. Harris
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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Tuson M, Yap M, Kok MR, Boruff B, Murray K, Vickery A, Turlach BA, Whyatt D. Improving the Efficiency of Geographic Target Regions for Healthcare Interventions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14721. [PMID: 36429437 PMCID: PMC9691133 DOI: 10.3390/ijerph192214721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
Appropriate prioritisation of geographic target regions (TRs) for healthcare interventions is critical to ensure the efficient distribution of finite healthcare resources. In delineating TRs, both 'targeting efficiency', i.e., the return on intervention investment, and logistical factors, e.g., the number of TRs, are important. However, existing approaches to delineate TRs disproportionately prioritise targeting efficiency. To address this, we explored the utility of a method found within conservation planning: the software Marxan and an extension, MinPatch ('Marxan + MinPatch'), with comparison to a new method we introduce: the Spatial Targeting Algorithm (STA). Using both simulated and real-world data, we demonstrate superior performance of the STA over Marxan + MinPatch, both with respect to targeting efficiency and with respect to adequate consideration of logistical factors. For example, by design, and unlike Marxan + MinPatch, the STA allows for user-specification of a desired number of TRs. More broadly, we find that, while Marxan + MinPatch does consider logistical factors, it also suffers from several limitations, including, but not limited to, the requirement to apply two separate software tools, which is burdensome. Given these results, we suggest that the STA could reasonably be applied to help prevent inefficiencies arising due to targeting of interventions using currently available approaches.
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Affiliation(s)
- Matthew Tuson
- Department of Mathematics and Statistics, The University of Western Australia, Crawley, WA 6009, Australia
| | - Matthew Yap
- Medical School, The University of Western Australia, Crawley, WA 6009, Australia
| | - Mei Ruu Kok
- Medical School, The University of Western Australia, Crawley, WA 6009, Australia
| | - Bryan Boruff
- UWA School of Agriculture and Environment, The University of Western Australia, Crawley, WA 6009, Australia
- Department of Geography, The University of Western Australia, Crawley, WA 6009, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Crawley, WA 6009, Australia
| | - Alistair Vickery
- Medical School, The University of Western Australia, Crawley, WA 6009, Australia
| | - Berwin A. Turlach
- Department of Mathematics and Statistics, The University of Western Australia, Crawley, WA 6009, Australia
| | - David Whyatt
- Medical School, The University of Western Australia, Crawley, WA 6009, Australia
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Chae SR, Lukupulo H, Kim S, Walker T, Hardy C, Abade A, Urio LJ, Mghamba J, Quick R. An Assessment of Household Knowledge and Practices during a Cholera Epidemic- Dar es Salaam, Tanzania, 2016. Am J Trop Med Hyg 2022; 107:766-772. [PMID: 36067990 PMCID: PMC9651532 DOI: 10.4269/ajtmh.21-0597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 03/05/2022] [Indexed: 12/30/2022] Open
Abstract
From August 15, 2015 to March 5, 2016, Tanzania reported 16,521 cholera cases and 251 deaths, with 4,596 cases and 44 deaths in its largest city, Dar es Salaam. To evaluate outbreak response efforts, we conducted a household survey with drinking water testing in the five most affected wards in Dar es Salaam. We interviewed 641 households 6 months after the beginning of the outbreak. Although most respondents knew that cholera causes diarrhea (90%) and would seek care if suspecting cholera (95%), only 45% were aware of the current outbreak in the area and only 5% would use oral rehydration salts (ORS) if ill. Of 200 (31%) respondents reporting no regular water treatment, 46% believed treatment was unnecessary and 18% believed treatment was too expensive. Fecal contamination was found in 45% of water samples and was associated with water availability (P = 0.047). Only 11% of samples had detectable free chlorine residual, which was associated with water availability (P = 0.025), reported current water treatment (P = 0.006), and observed free chlorine product in the household (P = 0.015). The provision of accessible, adequately chlorinated water supply, and implementation of social mobilization campaigns advocating household water treatment and use of ORS should be prioritized to address gaps in cholera prevention and treatment activities.
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Affiliation(s)
- Sae-Rom Chae
- Division of Foodborne and Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;,Address correspondence to Sae-Rom Chae, Division of Foodborne and Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA. E-mail:
| | - Haji Lukupulo
- Tanzania Field Epidemiology and Laboratory Training Program, Dar es Salaam, Tanzania
| | - Sunkyung Kim
- Division of Foodborne and Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tiffany Walker
- Division of Foodborne and Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Colleen Hardy
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ahmed Abade
- Tanzania Field Epidemiology and Laboratory Training Program, Dar es Salaam, Tanzania
| | - Loveness J. Urio
- Tanzania Field Epidemiology and Laboratory Training Program, Dar es Salaam, Tanzania
| | - Janneth Mghamba
- Ministry of Health, Community Development, Gender, Elderly and Children, United Republic of Tanzania, Dar es Salaam, Tanzania
| | - Robert Quick
- Division of Foodborne and Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Bisimwa L, Williams C, Bisimwa JC, Sanvura P, Endres K, Thomas E, Perin J, Cikomola C, Bengehya J, Maheshe G, Mwishingo A, George CM. Formative Research for the Development of Evidence-Based Targeted Water, Sanitation, and Hygiene Interventions to Reduce Cholera in Hotspots in the Democratic Republic of the Congo: Preventative Intervention for Cholera for 7 Days (PICHA7) Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12243. [PMID: 36231546 PMCID: PMC9566157 DOI: 10.3390/ijerph191912243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/18/2022] [Accepted: 09/05/2022] [Indexed: 06/16/2023]
Abstract
Compared to the general public, household members of cholera patients are at a 100 times higher risk of contracting cholera during the 7-day high-risk period after a cholera patient has been admitted to a health facility for treatment. The Preventative-Intervention-for-Cholera-for-7-days (PICHA7) program aims to reduce household transmission of cholera during this 7-day high-risk period through a health facility-initiated water, sanitation, and hygiene (WASH) program promoting handwashing with soap, water treatment, and safe water storage. The PICHA7 program is delivered to cholera patient households through: (1) a pictorial flipbook delivered by a health promoter; (2) a cholera prevention package (handwashing station, drinking water vessel with lid and tap, and chlorine tablets); and (3) weekly WASH mobile messages sent to patient households in the Democratic Republic of the Congo (DRC). The objectives of this study were to conduct formative research to identify facilitators and barriers of the promoted WASH behaviors for cholera patient households and to tailor the PICHA7 program to target these facilitators and barriers. Formative research included 93 semi-structured interviews with diarrhea patient households and healthcare workers during exploratory research and a pilot study of 518 participants. Barriers to the promoted WASH behaviors identified during exploratory and pilot study interviews included: (1) low awareness of cholera transmission and prevention; (2) unaffordability of soap for handwashing; and (3) intermittent access to water limiting water for handwashing. For intervention development, narratives of the lived experiences of patient households in our study were presented by health promoters to describe cholera transmission and prevention, and soapy water and ash were promoted in the program flipbook and mobile messages to address the affordability of soap for handwashing. A jerry can was provided to allow for additional water storage, and a tap with a slower flow rate was attached to the handwashing station to reduce the amount of water required for handwashing. The pilot findings indicate that the PICHA7 program has high user acceptability and is feasible to deliver to cholera patients that present at health facilities for treatment in our study setting. Formative research allowed for tailoring this targeted WASH program for cholera patient households in the DRC.
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Affiliation(s)
- Lucien Bisimwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Camille Williams
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Jean-Claude Bisimwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Presence Sanvura
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Kelly Endres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Elizabeth Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
| | - Cirhuza Cikomola
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Justin Bengehya
- Bureau de l’Information Sanitaire, Surveillance Epidémiologique et Recherche Scientifique Division Provinciale de la Santé/Sud Kivu, Ministère de la Santé Publique, Hygiène et Prévention, Bukavu B.P 265, Democratic Republic of the Congo
| | - Ghislain Maheshe
- Faculty of Medicine, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Alain Mwishingo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
- Center for Tropical Diseases & Global Health, Université Catholique de Bukavu, Bukavu B.P 265, Democratic Republic of the Congo
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA
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39
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Zheng Q, Luquero FJ, Ciglenecki I, Wamala JF, Abubakar A, Welo P, Hussen M, Wossen M, Yennan S, Keita A, Lessler J, Azman AS, Lee EC. Cholera outbreaks in sub-Saharan Africa during 2010-2019: a descriptive analysis. Int J Infect Dis 2022; 122:215-221. [PMID: 35605949 PMCID: PMC9439956 DOI: 10.1016/j.ijid.2022.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Cholera remains a public health threat but is inequitably distributed across sub-Saharan Africa. Lack of standardized reporting and inconsistent outbreak definitions limit our understanding of cholera outbreak epidemiology. METHODS From a database of cholera incidence and mortality, we extracted data from sub-Saharan Africa and reconstructed outbreaks of suspected cholera starting in January 2010 to December 2019 based on location-specific average weekly incidence rate thresholds. We then described the distribution of key outbreak metrics. RESULTS We identified 999 suspected cholera outbreaks in 744 regions across 25 sub-Saharan African countries. The outbreak periods accounted for 1.8 billion person-months (2% of the total during this period) from January 2010 to January 2020. Among 692 outbreaks reported from second-level administrative units (e.g., districts), the median attack rate was 0.8 per 1000 people (interquartile range (IQR), 0.3-2.4 per 1000), the median epidemic duration was 13 weeks (IQR, 8-19), and the median early outbreak reproductive number was 1.8 (range, 1.1-3.5). Larger attack rates were associated with longer times to outbreak peak, longer epidemic durations, and lower case fatality risks. CONCLUSIONS This study provides a baseline from which the progress toward cholera control and essential statistics to inform outbreak management in sub-Saharan Africa can be monitored.
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Affiliation(s)
- Qulu Zheng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Francisco J Luquero
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Global Alliance for Vaccines and Immunization (GAVI), Geneva, Switzerland
| | | | | | | | - Placide Welo
- PNECHOL-MD, Community IMCI, Ministry of Health, Democratic Republic of the Congo
| | - Mukemil Hussen
- Disease and Health Events Surveillance and Response Directorate, Ethiopia Public Health Institute, Addis Ababa, Ethiopia
| | - Mesfin Wossen
- Disease and Health Events Surveillance and Response Directorate, Ethiopia Public Health Institute, Addis Ababa, Ethiopia
| | - Sebastian Yennan
- Surveillance and Epidemiology, Nigeria Centre for Disease Control, Abuja, Nigeria
| | - Alama Keita
- Regional Office for West & Central Africa, UNICEF, Dakar, Senegal
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,Corresponding author
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Corresponding author
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Corresponding author
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40
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Moraga P, Baker L. rspatialdata: a collection of data sources and tutorials on downloading and visualising spatial data using R. F1000Res 2022; 11:770. [PMID: 36016994 PMCID: PMC9363973 DOI: 10.12688/f1000research.122764.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/20/2022] Open
Abstract
Spatial and spatio-temporal data are used in a wide range of fields including environmental, health and social disciplines. Several packages in the statistical software R have been recently developed as clients for various databases to meet the growing demands for easily accessible and reliable spatial data. While documentation on how to use many of these packages exist, there is an increasing need for a one stop repository for tutorials on this information. In this paper, we present rspatialdata a website that provides a collection of data sources and tutorials on downloading and visualising spatial data using R. The website includes a wide range of datasets including administrative boundaries of countries, Open Street Map data, population, temperature, vegetation, air pollution, and malaria data. The goal of the website is to equip researchers and communities with the tools to engage in spatial data analysis and visualisation so that they can address important local issues, such as estimating air pollution, quantifying disease burdens, and evaluating and monitoring the United Nation’s sustainable development goals.
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Affiliation(s)
- Paula Moraga
- Computer, Electrical and Mathematical Sciences and Engineering Division, King Abdullah University of Science and Technology (KAUST), Thuwal, 23955-6900, Saudi Arabia
| | - Laurie Baker
- College of the Atlantic, 105 Eden St, Bar Harbor, ME, 04609, USA
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41
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Kariuki S, Kering K, Wairimu C, Onsare R, Mbae C. Antimicrobial Resistance Rates and Surveillance in Sub-Saharan Africa: Where Are We Now? Infect Drug Resist 2022; 15:3589-3609. [PMID: 35837538 PMCID: PMC9273632 DOI: 10.2147/idr.s342753] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/16/2022] [Indexed: 01/03/2023] Open
Abstract
Introduction Although antimicrobials have traditionally been used to treat infections and improve health outcomes, resistance to commonly used antimicrobials has posed a major challenge. An estimated 700,000 deaths occur globally every year as a result of infections caused by antimicrobial-resistant pathogens. Antimicrobial resistance (AMR) also contributes directly to the decline in the global economy. In 2019, sub-Saharan Africa (SSA) had the highest mortality rate (23.5 deaths per 100,000) attributable to AMR compared to other regions. Methods We searched PubMed for articles relevant to AMR in pathogens in the WHO-GLASS list and in other infections of local importance in SSA. In this review, we focused on AMR rates and surveillance of AMR for these priority pathogens and some of the most encountered pathogens of public health significance. In addition, we reviewed the implementation of national action plans to mitigate against AMR in countries in SSA. Results and Discussion The SSA region is disproportionately affected by AMR, in part owing to the prevailing high levels of poverty, which result in a high burden of infectious diseases, poor regulation of antimicrobial use, and a lack of alternatives to ineffective antimicrobials. The global action plan as a strategy for prevention and combating AMR has been adopted by most countries, but fewer countries are able to fully implement country-specific action plans, and several challenges exist in many settings. Conclusion A concerted One Health approach will be required to ramp up implementation of action plans in the region. In addition to AMR surveillance, effective implementation of infection prevention and control, water, sanitation, and hygiene, and antimicrobial stewardship programs will be key cost-effective strategies in helping to tackle AMR.
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Affiliation(s)
- Samuel Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya,Correspondence: Samuel Kariuki, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya, Email
| | - Kelvin Kering
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Celestine Wairimu
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Robert Onsare
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Cecilia Mbae
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
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Hsiao A, Ramani E, Seo HJ, Pak G, Vuntade D, M'bang'ombe M, Ngwira B, Quentin W, Marks F, Mogasale V. Economic impact of cholera in households in rural southern Malawi: a prospective study. BMJ Open 2022; 12:e052337. [PMID: 35649608 PMCID: PMC9161053 DOI: 10.1136/bmjopen-2021-052337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 03/08/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Cholera remains a significant contributor to diarrhoeal illness, especially in sub-Saharan Africa. Few studies have estimated the cost of illness (COI) of cholera in Malawi, a cholera-endemic country. The present study estimated the COI of cholera in Nsanje, southern Malawi, as part of the Cholera Surveillance in Malawi (CSIMA) programme following a mass cholera vaccination campaign in 2015. METHODS Patients ≥12 months of age who were recruited as part of CSIMA were invited to participate in the COI survey. The COI tool captured household components of economic burden, including direct medical and non-medical costs, and indirect lost productivity costs. RESULTS Between April 2016 and March 2020, 40 cholera cases were enrolled in the study, all of whom participated in the COI survey. Only two patients had any direct medical costs and five patients reported lost wages due to illness. The COI per patient was US$14.34 (in 2020), more than half of which was from direct non-medical costs from food, water, and transportation to the health centre. CONCLUSION For the majority of Malawians who struggle to subsist on less than US$2 a day, the COI of cholera represents a significant cost burden to families. While cholera treatment is provided for free in government-run health centres, additional investments in cholera control and prevention at the community level and financial support beyond direct medical costs may be necessary to alleviate the economic burden of cholera on households in southern Malawi.
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Affiliation(s)
- Amber Hsiao
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Enusa Ramani
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
- Policy and Economic Research, International Vaccine Institute, Seoul, The Republic of Korea
| | - Hye-Jin Seo
- Epidemiology, Public Health, Impact, International Vaccine Institute, Seoul, The Republic of Korea
| | - GiDeok Pak
- Biostatistics & Data Management, International Vaccine Institute, Seoul, The Republic of Korea
| | - Dan Vuntade
- Department of Environmental Health, University of Malawi the Polytechnic, Blantyre, Malawi
| | | | - Bagrey Ngwira
- Department of Environmental Health, University of Malawi the Polytechnic, Blantyre, Malawi
| | - Wilm Quentin
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Florian Marks
- Epidemiology, Public Health, Impact, International Vaccine Institute, Gwanak-gu, The Republic of Korea
- Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge Institute of Therapeutic Immunology and Infectious Disease, Cambridge, UK
| | - Vittal Mogasale
- Policy and Economic Research, International Vaccine Institute, Seoul, The Republic of Korea
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Perez-Saez J, Lessler J, Lee EC, Luquero FJ, Malembaka EB, Finger F, Langa JP, Yennan S, Zaitchik B, Azman AS. The seasonality of cholera in sub-Saharan Africa: a statistical modelling study. THE LANCET GLOBAL HEALTH 2022; 10:e831-e839. [PMID: 35461521 PMCID: PMC9090905 DOI: 10.1016/s2214-109x(22)00007-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background Cholera remains a major threat in sub-Saharan Africa (SSA), where some of the highest case-fatality rates are reported. Knowing in what months and where cholera tends to occur across the continent could aid in improving efforts to eliminate cholera as a public health concern. However, largely due to the absence of unified large-scale datasets, no continent-wide estimates exist. In this study, we aimed to estimate cholera seasonality across SSA and explore the correlation between hydroclimatic variables and cholera seasonality. Methods Using the global cholera database of the Global Task Force on Cholera Control, we developed statistical models to synthesise data across spatial and temporal scales to infer the seasonality of excess (defined as incidence higher than the 2010–16 mean incidence rate) suspected cholera occurrence in SSA. We developed a Bayesian statistical model to infer the monthly risk of excess cholera at the first and second administrative levels. Seasonality patterns were then grouped into spatial clusters. Finally, we studied the association between seasonality estimates and hydroclimatic variables (mean monthly fraction of area flooded, mean monthly air temperature, and cumulative monthly precipitation). Findings 24 (71%) of the 34 countries studied had seasonal patterns of excess cholera risk, corresponding to approximately 86% of the SSA population. 12 (50%) of these 24 countries also had subnational differences in seasonality patterns, with strong differences in seasonality strength between regions. Seasonality patterns clustered into two macroregions (west Africa and the Sahel vs eastern and southern Africa), which were composed of subregional clusters with varying degrees of seasonality. Exploratory association analysis found most consistent and positive correlations between cholera seasonality and precipitation and, to a lesser extent, between cholera seasonality and temperature and flooding. Interpretation Widespread cholera seasonality in SSA offers opportunities for intervention planning. Further studies are needed to study the association between cholera and climate. Funding US National Aeronautics and Space Administration Applied Sciences Program and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Javier Perez-Saez
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Unité d'Épidémiologie Populationnelle, Geneva University Hospitals, Geneva, Switzerland
| | - Justin Lessler
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Gillings School of Global Public Health, and University of North Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth C Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Espoir Bwenge Malembaka
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | | | | | - Sebastian Yennan
- Surveillance and Epidemiology, Nigeria Centre for Disease Control, Abuja, Nigeria
| | - Benjamin Zaitchik
- Department of Earth and Planetary Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Unité d'Épidémiologie Populationnelle, Geneva University Hospitals, Geneva, Switzerland; Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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D'Mello-Guyett L, Cumming O, Rogers E, D'hondt R, Mengitsu E, Mashako M, Van den Bergh R, Welo PO, Maes P, Checchi F. Identifying transferable lessons from cholera epidemic responses by Médecins Sans Frontières in Mozambique, Malawi and the Democratic Republic of Congo, 2015-2018: a scoping review. Confl Health 2022; 16:12. [PMID: 35351171 PMCID: PMC8966369 DOI: 10.1186/s13031-022-00445-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 03/16/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cholera epidemics occur frequently in low-income countries affected by concurrent humanitarian crises. Evaluations of these epidemic response remains largely unpublished and there is a need to generate evidence on response efforts to inform future programmes. This review of MSF cholera epidemic responses aimed to describe the main characteristics of the cholera epidemics and related responses in these three countries, to identify challenges to different intervention strategies based on available data; and to make recommendations for epidemic prevention and control practice and policy. METHODS Case studies from the Democratic Republic of Congo, Malawi and Mozambique were purposively selected by MSF for this review due to the documented burden of cholera in each country, frequency of cholera outbreaks, and risk of humanitarian crises. Data were extracted on the characteristics of the epidemics; time between alert and response; and, the delivery of health and water, sanitation and hygiene interventions. A Theory of Change for cholera response programmes was built to assess factors that affected implementation of the responses. RESULTS AND CONCLUSIONS 20 epidemic response reports were identified, 15 in DRC, one in Malawi and four in Mozambique. All contexts experienced concurrent humanitarian crises, either armed conflict or natural disasters. Across the settings, median time between the date of alert and date of the start of the response by MSF was 23 days (IQR 14-41). Almost all responses targeted interventions community-wide, and all responses implemented in-patient treatment of suspected cholera cases in either established health care facilities (HCFs) or temporary cholera treatment units (CTUs). In three responses, interventions were delivered as case-area targeted interventions (CATI) and four responses targeted households of admitted suspected cholera cases. CATI or delivery of interventions to households of admitted suspected cases occurred from 2017 onwards only. Overall, 74 factors affecting implementation were identified including delayed supplies of materials, insufficient quantities of materials and limited or lack of coordination with local government or other agencies. Based on this review, the following recommendations are made to improve cholera prevention and control efforts: explore improved models for epidemic preparedness, including rapid mobilisation of supplies and deployment of trained staff; invest in and strengthen partnerships with national and local government and other agencies; and to standardise reporting templates that allow for rigorous and structured evaluations within and across countries to provide consistent and accessible data.
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Affiliation(s)
- Lauren D'Mello-Guyett
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium.
| | - Oliver Cumming
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Elliot Rogers
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Rob D'hondt
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | | | - Maria Mashako
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Rafael Van den Bergh
- LuxOR, Luxembourg Operational Research Unit, Médecins Sans Frontières, Luxembourg, Luxembourg
| | - Placide Okitayemba Welo
- Programme National d'Elimination du Choléra et de lutte contre les autres Maladies Diarrhéiques, Kinshasa, Democratic Republic of Congo
| | - Peter Maes
- WASH Section, UNICEF, Kinshasa, Democratic Republic of Congo
| | - Francesco Checchi
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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45
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Awuor SO, Omwenga EO, Mariita RM, Daud II. Cholera outbreak: antibiofilm activity, profiling of antibiotic-resistant genes and virulence factors of toxigenic Vibrio cholerae isolates reveals concerning traits. Access Microbiol 2022; 4:000324. [PMID: 35693465 PMCID: PMC9175979 DOI: 10.1099/acmi.0.000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022] Open
Abstract
Vibrio cholerae is a biofilm-forming pathogen with various virulence phenotypes and antimicrobial resistance traits. Phenotypic characteristics play a critical role in disease transmission and pathogenesis. The current study elucidated antibiofilm formation activity, profiled antibiotic-resistant genes and virulence factors of toxigenic Vibrio cholerae isolates from the cholera outbreak in Kisumu County, Kenya. Vibrio cholerae O1 isolates collected during the 2017 cholera outbreak in Kisumu County, Kenya, were utilized. Biofilm and virulence factors were profiled using standard procedures. The study confirmed 100 isolates as Vibrio cholerae, with 81 of them possessing cholera toxin gene (ctxA). Additionally, 99 of the isolates harboured the toxR gene. The study further revealed that 81 and 94 of the isolates harboured the class I integron (encoded by inDS gene) and integrating conjugative element (ICE), respectively. Antibiotic resistance assays confirmed tetracycline resistance genes as the most abundant (97 isolates). Among them were seven isolates resistant to commonly used antibiotics. The study further screened the isolates for antibiofilm formation using various antibiotics. Unlike the four strains (03/17–16, 02/17–09, 04/17–13), three of the strains (04/17–07, 06/17–14 and 05/17–03) did not form biofilms. Further, all the seven isolates that exhibited extensive antibiotic resistance produced haemolysin while 71.42%, 85.71 and 71.42 % of them produced protease, phospholipases and lipase, respectively. This study provides and in-depth understanding of essential features that were possibly responsible for V. cholerae outbreak. Understanding of these features is critical in the development of strategies to combat future outbreaks.
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Affiliation(s)
- Silas O. Awuor
- School of Health Sciences, Kisii University, P.O BOX 408-40200 Kisii, Kenya
| | - Eric O. Omwenga
- School of Health Sciences, Kisii University, P.O BOX 408-40200 Kisii, Kenya
| | | | - Ibrahim I. Daud
- Kenya Medical Research Institute, United States Army Medical Research Directorate-Africa, HJF Medical Research International, Kericho, Kenya
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46
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Shahparvari S, Hassanizadeh B, Mohammadi A, Kiani B, Lau KH, Chhetri P, Abbasi B. A decision support system for prioritised COVID-19 two-dosage vaccination allocation and distribution. TRANSPORTATION RESEARCH. PART E, LOGISTICS AND TRANSPORTATION REVIEW 2022; 159:102598. [PMID: 35185357 PMCID: PMC8843424 DOI: 10.1016/j.tre.2021.102598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 08/23/2021] [Accepted: 12/23/2021] [Indexed: 05/12/2023]
Abstract
This study proposes a decision support system (DSS) that integrates GIS, analytics, and simulation methods to help develop a priority-based distribution of COVID-19 vaccines in a large urban setting. The methodology applies novel hierarchical heuristic-simulation procedures to create a holistic algorithm for prioritising the process of demand allocation and optimising vaccine distribution. The Melbourne metropolitan area in Australia with a population of over five million is used as a case study. Three vaccine supply scenarios, namely limited, excessive, and disruption, were formulated to operationalise a two-dose vaccination program. Vaccine distribution with hard constraints were simulated and then further validated with sensitivity analyses. The results show that vaccines can be prioritised to society's most vulnerable segments and distributed using the current logistics network with 10 vehicles. Compared with other vaccine distribution plans with no prioritisation, such as equal allocation of vaccines to local government areas based on population size or one on a first-come-first-serve basis, the plans generated by the proposed DSS ensure prioritised vaccination of the most needed and vulnerable population. The aim is to curb the spread of the infection and reduce mortality rate more effectively. They also achieve vaccination of the entire population with less logistical resources required. As such, this study contributes to knowledge and practice in pandemic vaccine distribution and enables governments to make real-time decisions and adjustments in daily distribution plans. In this way any unforeseen disruptions in the vaccine supply chain can be coped with.
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Affiliation(s)
- Shahrooz Shahparvari
- School of Accounting Information Systems & Supply Chain, RMIT University, Melbourne, VIC, Australia
| | | | - Alireza Mohammadi
- Department of Geography & Planning, Faculty of Social Sciences, University of Mohaghegh Ardabili, Ardabil, Iran
| | - Behzad Kiani
- Department of Medical Informatics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kwok Hung Lau
- School of Accounting Information Systems & Supply Chain, RMIT University, Melbourne, VIC, Australia
| | - Prem Chhetri
- School of Accounting Information Systems & Supply Chain, RMIT University, Melbourne, VIC, Australia
| | - Babak Abbasi
- School of Accounting Information Systems & Supply Chain, RMIT University, Melbourne, VIC, Australia
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47
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Azman AS, Ciglenecki I, Luquero FJ. Putting rapid tests to work in surveillance and control of cholera. Clin Microbiol Infect 2022; 28:152-154. [PMID: 34757118 PMCID: PMC10711571 DOI: 10.1016/j.cmi.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/17/2021] [Accepted: 10/22/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Médecins sans Frontières, Geneva, Switzerland; Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | | | - Francisco J Luquero
- Gavi, the Vaccine Alliance, Geneva, Switzerland; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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48
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Kruger SE, Lorah PA, Okamoto KW. Mapping climate change's impact on cholera infection risk in Bangladesh. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000711. [PMID: 36962590 PMCID: PMC10021506 DOI: 10.1371/journal.pgph.0000711] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/10/2022] [Indexed: 03/26/2023]
Abstract
Several studies have investigated how Vibrio cholerae infection risk changes with increased rainfall, temperature, and water pH levels for coastal Bangladesh, which experiences seasonal surges in cholera infections associated with heavy rainfall events. While coastal environmental conditions are understood to influence V. cholerae propagation within brackish waters and transmission to and within human populations, it remains unknown how changing climate regimes impact the risk for cholera infection throughout Bangladesh. To address this, we developed a random forest species distribution model to predict the occurrence probability of cholera incidence within Bangladesh for 2015 and 2050. We developed a random forest model trained on cholera incidence data and spatial environmental raster data to be predicted to environmental data for the year of training (2015) and 2050. From our model's predictions, we generated risk maps for cholera occurrence for 2015 and 2050. Our best-fitting model predicted cholera occurrence given elevation and distance to water. Generally, we find that regions within every district in Bangladesh experience an increase in infection risk from 2015 to 2050. We also find that although cells of high risk cluster along the coastline predominantly in 2015, by 2050 high-risk areas expand from the coast inland, conglomerating around surface waters across Bangladesh, reaching all but the northwestern-most district. Mapping the geographic distribution of cholera infections given projected environmental conditions provides a valuable tool for guiding proactive public health policy tailored to areas most at risk of future disease outbreaks.
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Affiliation(s)
- Sophia E Kruger
- Department of Biology, University of St. Thomas, St. Paul, Minnesota, United States of America
- School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Paul A Lorah
- Department of Earth, Environment and Society, University of St. Thomas, St. Paul, Minnesota, United States of America
| | - Kenichi W Okamoto
- Department of Biology, University of St. Thomas, St. Paul, Minnesota, United States of America
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49
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Charnley GEC, Yennan S, Ochu C, Kelman I, Gaythorpe KAM, Murray KA. The impact of social and environmental extremes on cholera time varying reproduction number in Nigeria. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000869. [PMID: 36962831 PMCID: PMC10022205 DOI: 10.1371/journal.pgph.0000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/10/2022] [Indexed: 12/15/2022]
Abstract
Nigeria currently reports the second highest number of cholera cases in Africa, with numerous socioeconomic and environmental risk factors. Less investigated are the role of extreme events, despite recent work showing their potential importance. To address this gap, we used a machine learning approach to understand the risks and thresholds for cholera outbreaks and extreme events, taking into consideration pre-existing vulnerabilities. We estimated time varying reproductive number (R) from cholera incidence in Nigeria and used a machine learning approach to evaluate its association with extreme events (conflict, flood, drought) and pre-existing vulnerabilities (poverty, sanitation, healthcare). We then created a traffic-light system for cholera outbreak risk, using three hypothetical traffic-light scenarios (Red, Amber and Green) and used this to predict R. The system highlighted potential extreme events and socioeconomic thresholds for outbreaks to occur. We found that reducing poverty and increasing access to sanitation lessened vulnerability to increased cholera risk caused by extreme events (monthly conflicts and the Palmers Drought Severity Index). The main limitation is the underreporting of cholera globally and the potential number of cholera cases missed in the data used here. Increasing access to sanitation and decreasing poverty reduced the impact of extreme events in terms of cholera outbreak risk. The results here therefore add further evidence of the need for sustainable development for disaster prevention and mitigation and to improve health and quality of life.
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Affiliation(s)
- Gina E C Charnley
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Sebastian Yennan
- Surveillance and Epidemiology Department/IM Cholera, Nigeria Centre for Disease Control, Abuja, Nigeria
| | - Chinwe Ochu
- Surveillance and Epidemiology Department/IM Cholera, Nigeria Centre for Disease Control, Abuja, Nigeria
| | - Ilan Kelman
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
- University of Agder, Kristiansand, Norway
| | - Katy A M Gaythorpe
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Kris A Murray
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
- MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gamiba
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50
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Sack DA, Debes AK, Ateudjieu J, Bwire G, Ali M, Ngwa MC, Mwaba J, Chilengi R, Orach CC, Boru W, Mohamed AA, Ram M, George CM, Stine OC. Contrasting Epidemiology of Cholera in Bangladesh and Africa. J Infect Dis 2021; 224:S701-S709. [PMID: 34549788 PMCID: PMC8687066 DOI: 10.1093/infdis/jiab440] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In Bangladesh and West Bengal cholera is seasonal, transmission occurs consistently annually. By contrast, in most African countries, cholera has inconsistent seasonal patterns and long periods without obvious transmission. Transmission patterns in Africa occur during intermittent outbreaks followed by elimination of that genetic lineage. Later another outbreak may occur because of reintroduction of new or evolved lineages from adjacent areas, often by human travelers. These then subsequently undergo subsequent elimination. The frequent elimination and reintroduction has several implications when planning for cholera's elimination including: a) reconsidering concepts of definition of elimination, b) stress on rapid detection and response to outbreaks, c) more effective use of oral cholera vaccine and WASH, d) need to readjust estimates of disease burden for Africa, e) re-examination of water as a reservoir for maintaining endemicity in Africa. This paper reviews major features of cholera's epidemiology in African countries which appear different from the Ganges Delta.
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Affiliation(s)
- David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amanda K Debes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jerome Ateudjieu
- Meilleur Acces aux Soins de Sante, and Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, and Clinical Research Unit, Division of Health Operations Research, Cameroon Ministry of Public Health, Yaoundé, Cameroon
| | - Godfrey Bwire
- Department of Integrated Epidemiology, Surveillance, and Public Health Emergencies, Ministry of Health, Kampala, Uganda
| | - Mohammad Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Moise Chi Ngwa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John Mwaba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Christopher C Orach
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Waqo Boru
- Ministry of Health and Field Epidemiology and Laboratory Training Program, Nairobi, Kenya
| | - Ahmed Abade Mohamed
- Tanzania Field Epidemiology and Laboratory Training Program, Dar-es-Salaam, Tanzania
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - O Colin Stine
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland, USA
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