Individual and household exposures associated with cholera transmission in case–control studies: a systematic review

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

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.

A Combination of Metagenomic and Cultivation Approaches Reveals Hypermutator Phenotypes within Vibrio cholerae-Infected Patients

Vibrio cholerae can cause a range of symptoms, from severe diarrhea to asymptomatic infection. Previous studies using whole-genome sequencing (WGS) of multiple bacterial isolates per patient showed that V. cholerae can evolve modest genetic diversity during symptomatic infection. To further explore the extent of V. cholerae within-host diversity, we applied culture-based WGS and metagenomics to a cohort of both symptomatic and asymptomatic cholera patients from Bangladesh. While metagenomics allowed us to detect more mutations in symptomatic patients, WGS of cultured isolates was necessary to detect V. cholerae diversity in asymptomatic carriers, likely due to their low V. cholerae load. Using both metagenomics and isolate WGS, we report three lines of evidence that V. cholerae hypermutators evolve within patients. First, we identified nonsynonymous mutations in V. cholerae DNA repair genes in 5 out of 11 patient metagenomes sequenced with sufficient coverage of the V. cholerae genome and in 1 of 3 patients with isolate genomes sequenced. Second, these mutations in DNA repair genes tended to be accompanied by an excess of intrahost single nucleotide variants (iSNVs). Third, these iSNVs were enriched in transversion mutations, a known hallmark of hypermutator phenotypes. While hypermutators appeared to generate mostly selectively neutral mutations, nonmutators showed signs of convergent mutation across multiple patients, suggesting V. cholerae adaptation within hosts. Our results highlight the power and limitations of metagenomics combined with isolate sequencing to characterize within-patient diversity in acute V. cholerae infections, while providing evidence for hypermutator phenotypes within cholera patients.

IMPORTANCE Pathogen evolution within patients can impact phenotypes such as drug resistance and virulence, potentially affecting clinical outcomes. V. cholerae infection can result in life-threatening diarrheal disease or asymptomatic infection. Here, we describe whole-genome sequencing of V. cholerae isolates and culture-free metagenomic sequencing from stool of symptomatic cholera patients and asymptomatic carriers. Despite the typically short duration of cholera, we found evidence for adaptive mutations in the V. cholerae genome that occur independently and repeatedly within multiple symptomatic patients. We also identified V. cholerae hypermutator phenotypes within several patients, which appear to generate mainly neutral or deleterious mutations. Our work sets the stage for future studies of the role of hypermutators and within-patient evolution in explaining the variation from asymptomatic carriage to symptomatic cholera.

Sachet water consumption as a risk factor for cholera in urban settings: Findings from a case control study in Kinshasa, Democratic Republic of the Congo during the 2017-2018 outbreak

Background

Behavioural risk factors for cholera are well established in rural and semi-urban contexts, but not in densely populated mega-cities in Sub-Saharan Africa. In November 2017, a cholera epidemic occurred in Kinshasa, the Democratic Republic of the Congo, where no outbreak had been recorded for nearly a decade. During this outbreak, we investigated context-specific risk factors for cholera in an urban setting among a population that is not frequently exposed to cholera.

Methodology/Principal findings

We recruited 390 participants from three affected health zones of Kinshasa into a 1:1 matched case control study. Cases were identified from cholera treatment centre admission records, while controls were recruited from the vicinity of the cases’ place of residence. We used standardized case report forms for the collection of socio-demographic and behavioural risk factors. We used augmented backward elimination in a conditional logistic regression model to identify risk factors.

The consumption of sachet water was strongly associated with the risk of being a cholera case (p-value 0.019), which increased with increasing frequency of consumption from rarely (OR 2.2, 95% CI 0.9–5.2) to often (OR 4.0, 95% CI 1.6–9.9) to very often (OR 4.1, 95% CI 1.0–16.7). Overall, more than 80% of all participants reported consumption of this type of drinking water. The risk factors funeral attendance and contact with someone suffering from diarrhoea showed a p-value of 0.09 and 0.08, respectively. No socio-demographic characteristics were associated with the risk of cholera.

Conclusions/Significance

Drinking water consumption from sachets, which are sold informally on the streets in most Sub-Saharan African cities, are an overlooked route of infection in urban cholera outbreaks. Outbreak response measures need to acknowledge context-specific risk factors to remain a valuable tool in the efforts to achieve national and regional targets to reduce the burden of cholera in Sub-Saharan Africa.

Cholera is a diarrheal disease caused by ingestion of the Vibrio cholerae bacterium. Outbreaks in urban areas are becoming increasingly frequent in Sub-Saharan Africa. Risk factors for cholera have been studied in rural settings but not sufficiently in urban areas. Understanding context-specific risk factors is key for successful outbreak response. During a cholera outbreak in Kinshasa, the Democratic Republic of the Congo we were able to identify a previously unknown behavioural risk factor of particular relevance in urban settings–the consumption of drinking water from plastic sachets. Water sachets are sold on the streets of all major cities in Sub-Saharan Africa. It requires biting off an edge and sucking out the water, and we think that external contamination of these sachets was an important transmission route in the Kinshasa outbreak. Water sachets are predominantly consumed by socio-economically disadvantaged groups who lack piped water supply in their homes and have poor access to sanitary infrastructure. This makes our findings particularly relevant because these are the very populations who are at increased risk of getting and transmitting cholera. Health messaging and response measures should include consumption of water sachets as a potential risk factor during future cholera outbreaks in urban low-resource settings.

Historical and contemporary views on cholera transmission: are we repeating past discussions? Can lessons learned from cholera be applied to COVID-19?

Cholera, a devastating diarrheal disease that caused several global pandemics in the last centuries, may share some similarities with the new COVID‐19. Cholera has affected many populations in history and still remains a significant burden in developing countries. The main transmission route was thought to be predominantly through contaminated drinking water. However, revisiting the historical data collected during the Copenhagen 1853 cholera outbreak allowed us to re‐evaluate the role of drinking‐water transmission in a city‐wide outbreak and reconsider some critical transmission routes, which have been neglected since the time of John Snow. Recent empirical and cohort data from Bangladesh also strengthened the dynamic potentiality of other transmission routes (food, fomite, fish, flies) for transmitting cholera. Analyzing this particular nature of the cholera disease transmission, this paper will describe how the pattern of transmission routes are similar to COVID‐19 and how the method of revisiting old data can be used for further exploration of new and known diseases.

Water usage, hygiene and diarrhea in low-income urban communities-A mixed method prospective longitudinal study

Epidemiological studies considered water use and hygiene practices as central risk factors for diarrhea. Few studies focused on independent association of water quantity with diarrheal diseases. This study aimed to describe the methodological protocol that adapted multidisciplinary and mixed-method research approach to assess how water usage including water quantity influences the attributable risk for diarrhea in a low-income urban community in Bangladesh.

The quantitative, anthropological and microbiological approaches were threaded together to provide a greater understanding of the infrastructural, behavioral and microbial interactions to fathom the dimensions of fecal oral transmission pathways within the households. The use of the 'Choleraphone' (i.e. a mobile phone based real time diarrheal reporting system) was a contemporary approach intended to cut down on resources, reduce research fatigue and provide more accurate data compared to the 'gold standard' (i.e. visiting a household of diarrhea cases within 48 hours) for measuring diarrhea incidence. Development of methods to measure water quantity using qualitative and quantitative approach within a setting where meter water connection is rare was another unique feature of this protocol. This protocol provided guidance and insight on how multiple methods of different disciplines can be combined to enrich understanding of waterborne diseases.