Distribution of hygiene kits during a cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo: a process evaluation

The epidemiological profile of incidence and mortality from epidemics in complex humanitarian emergencies from 1990 to 2022 - A scoping review

AIM

This study aimed to investigate the impact of communicable diseases with epidemic potential in complex emergency (CE) situations, focusing on the epidemiological profile of incidence and mortality and exploring underlying factors contributing to increased epidemic risks.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) guidelines, we conducted a scoping review of articles published between 1990 and 2022. The search included terms related to complex emergencies, communicable diseases, outbreaks, and epidemics. We identified 92 epidemics related to CE occurring in 32 different countries.

RESULTS

Communicable diseases like Shigellosis, Cholera, Measles, Meningococcal meningitis, Yellow Fever, and Malaria caused significant morbidity and mortality. Diarrhoeal diseases, particularly Cholera and Shigellosis, had the highest incidence rates. Shigella specifically had an incidence of 241.0 per 1000 (people at risk), with a mortality rate of 11.7 per 1000, while Cholera's incidence was 13.0 per 1000, with a mortality rate of 0.22 per 1000. Measles followed, with an incidence of 25.0 per 1000 and a mortality rate of 0.76 per 1000. Meningococcal Meningitis had an incidence rate of 1.3 per 1000 and a mortality rate of 0.13 per 1000. Despite their lower incidences, yellow fever at 0.8 per 1000 and malaria at 0.4 per 1000, their high case fatality rates of 20.1% and 0.4% remained concerning in CE. The qualitative synthesis reveals that factors such as water, sanitation, and hygiene, shelter and settlements, food and nutrition, and public health and healthcare in complex emergencies affect the risk of epidemics.

CONCLUSION

Epidemics during complex emergencies could potentially lead to a public health crisis. Between 1990 and 2022, there have been no statistically significant changes in the trend of incidence, mortality, or fatality rates of epidemic diseases in CE. It is crucial to understand that all epidemics identified in CE are fundamentally preventable.

A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo

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.

Burial workers' perceptions of community resistance and support systems during an Ebola outbreak in the Eastern Democratic Republic of the Congo: a qualitative study

BACKGROUND

Community Health Workers (CHWs) provide vital services during disease outbreaks. Appropriate burials of those who died from an infectious disease outbreak is a critical CHW function to prevent infection and disease spread. During the 2018 Ebola Virus Disease (EVD) outbreak in Beni Town, North Kivu, Democratic Republic of the Congo, we sought to understand the levels of understanding, trust, and cooperation of the community in response to the outbreak, the barriers burial workers faced in their health work and its impact on local burial workers and other CHWs.

METHODS

12 EVD burial CHWs in Beni Town completed an hour-long qualitative in-depth interview on their experiences. They were recruited from a local counseling center. Interviews were recorded, transcribed and translated into English. A team of 3 researchers identified structural and emergent themes using applied thematic analysis.

RESULTS

Workers reported major misconceptions in the community surrounding the initiation of the outbreak. Community misconceptions were based on widespread governmental mistrust as well as a belief system that intertwines traditional and scientific understandings of the world. EVD burial workers identified violence directed at them and community misinformation as the two largest barriers to effectively carrying out their work. They named several important support systems including family and friends, personal relaxation techniques, and a local counseling center.

CONCLUSIONS

As with other disease outbreaks globally, we found that government mistrust and religious beliefs strongly impacted community perceptions of the EVD outbreak. Previous studies have demonstrated clinic-based medical personnel are often the targets of violence. Our research shows that burial workers were also targeted and exposed to extreme levels of violence in their work. Along with their ability to effectively respond to the outbreak, violence has a negative impact on their own mental wellbeing. Burial workers found group counseling sessions to be an effective tool for managing the stress associated with their work. Further developing and testing of group-based interventions for this group is a priority for future research.

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

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00445-1.

Accessing sub-national cholera epidemiological data for Nigeria and the Democratic Republic of Congo during the seventh pandemic

BACKGROUND

Vibrio cholerae is a water-borne pathogen with a global burden estimate at 1.4 to 4.0 million annual cases. Over 94% of these cases are reported in Africa and more research is needed to understand cholera dynamics in the region. Cholera data are lacking, mainly due to reporting issues, creating barriers for widespread research on cholera epidemiology and management in Africa.

MAIN BODY

Here, we present datasets that were created to help address this gap, collating freely available sub-national cholera data for Nigeria and the Democratic Republic of Congo. The data were collated from a variety of English and French publicly available sources, including the World Health Organization, PubMed, UNICEF, EM-DAT, the Nigerian CDC and peer-reviewed literature. These data include information on cases, deaths, age, gender, oral cholera vaccination, risk factors and interventions.

CONCLUSION

These datasets can facilitate qualitative, quantitative and mixed methods research in these two high burden countries to assist in public health planning. The data can be used in collaboration with organisations in the two countries, which have also collected data or undertaking research. By making the data and methods available, we aim to encourage their use and further data collection and compilation to help improve the data gaps for cholera in Africa.

Assessment of potential factors that support the endemicity of cholera in Nigeria from food handlers, health workers and the environment

Background and Aims: Diarrheal diseases caused by bacterial pathogens are widespread and they result in morbidity and mortality of a lot of people yearly. The aim of this study was to assess the role of the environment, health workers and food handlers as reservoirs of Vibrio cholerae, and other diarrhea causing bacteria. Methods: Healthcare workers were proportionally selected and multistage sampling technique was adopted in selecting food handlers for the study. A total of 374 participants consisting of health workers and food handlers were recruited. Socio-demographic and clinical information were collected using questionnaires, while stool and environmental samples were also collected. Results: More female 55.9 % than male 44.1 % participated in the study and the mean age of participants was 38.7 ± 10.9. A significant number of participants identified poor hygiene practices as the major cause of diarrhea. V. cholerae O1 serotype was not detected in any of the environmental samples nor stool samples of both food handlers and health workers. However, V. cholerae (Non O1/Non O139) was isolated from the stool samples of food handlers and health workers in Kano State implying that they could be serving a source of the continuous dissemination of the pathogen. Other bacterial pathogens that are aetiology of diarrhea including Salmonella spp. Escherichia coli, Klebsiella oxytoca, and Enterobacter spp. were also isolated. Conclusion: It is therefore imperative that food handlers and health workers undergo periodic health checks to ensure they are free of pathogens they could easily transmit through food or to patients.

Effectiveness of hygiene kit distribution to reduce cholera transmission in Kasaï-Oriental, Democratic Republic of Congo, 2018: a prospective cohort study

INTRODUCTION

Household contacts of cholera cases are at a greater risk of Vibrio cholerae infection than the general population. There is currently no agreed standard of care for household contacts, despite their high risk of infection, in cholera response strategies. In 2018, hygiene kit distribution and health promotion was recommended by Médecins Sans Frontières for admitted patients and accompanying household members on admission to a cholera treatment unit in the Democratic Republic of Congo.

METHODS

To investigate the effectiveness of the intervention and risk factors for cholera infection, we conducted a prospective cohort study and followed household contacts for 7 days after patient admission. Clinical surveillance among household contacts was based on self-reported symptoms of cholera and diarrhoea, and environmental surveillance through the collection and analysis of food and water samples.

RESULTS

From 94 eligible households, 469 household contacts were enrolled and 444 completed follow-up. Multivariate analysis suggested evidence of a dose-response relationship with increased kit use associated with decreased relative risk of suspected cholera: household contacts in the high kit-use group had a 66% lower incidence of suspected cholera (adjusted risk ratio (aRR) 0.34, 95% CI 0.11 to 1.03, p=0.055), the mid-use group had a 53% lower incidence (aRR 0.47, 95% CI 0.17 to 1.29, p=1.44) and low-use group had 22% lower incidence (aRR 0.78, 95% CI 0.24 to 2.53, p=0.684), compared with household contacts without a kit. Drinking water contamination was significantly reduced among households in receipt of a kit. There was no significant effect on self-reported diarrhoea or food contamination.

CONCLUSION

The integration of a hygiene kit intervention to case-households may be effective in reducing cholera transmission among household contacts and environmental contamination within the household. Further work is required to evaluate whether other proactive localised distribution among patients and case-households or to households surrounding cholera cases can be used in future cholera response programmes in emergency contexts.

An exploratory pilot study of the effect of modified hygiene kits on handwashing with soap among internally displaced persons in Ethiopia

Background

Internally displaced persons fleeing their homes due to conflict and drought are particularly at risk of morbidity and mortality from diarrhoeal diseases. Regular handwashing with soap (HWWS) could substantially reduce the risk of these infections, but the behaviour is challenging to practice while living in resource-poor, informal settlements. To mitigate these challenges, humanitarian aid organisations distribute hygiene kits, including soap and handwashing infrastructure. Our study aimed to assess the effect of modified hygiene kits on handwashing behaviours among internally displaced persons in Moyale, Ethiopia.

Methods

The pilot study evaluated three interventions: providing liquid soap; scented soap bar; and the inclusion of a mirror in addition to the standard hygiene kit. The hygiene kits were distributed to four study arms. Three of the arms received one of the interventions in addition to the standard hygiene kit. Three to six weeks after distribution the change in behaviour and perceptions of the interventions were assessed through structured observations, surveys and focus group discussions.

Results

HWWS was rare at critical times for all study arms. In the liquid soap arm, HWWS was observed for only 20% of critical times. This result was not indicated significantly different from the control arm which had a prevalence of 17% (p-value = 0.348). In the mirror and scented soap bar intervention arms, HWWS prevalence was 11 and 10%, respectively. This was indicated to be significantly different from the control arm. Participants in the focus group discussions indicated that liquid soap, scented soap bar and the mirror made handwashing more desirable. In contrast, participants did not consider the soap bar normally distributed in hygiene kits as nice to use.

Conclusion

We found no evidence of an increased prevalence of handwashing with soap following distribution of the three modified hygiene kits. However, our study indicates the value in better understanding hygiene product preferences as this may contribute to increased acceptability and use among crisis-affected populations. The challenges of doing research in a conflict-affected region had considerable implications on this study’s design and implementation.

Trial registration

The trial was registered at www.ClinicalTrials.gov 6 September 2019 (reg no: NCT04078633).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00368-3.

Influence of Community-Led Total Sanitation and Water Coverages in the Control of Cholera in Madarounfa, Niger (2018)

Every year, cholera affects 1.3-4.0 million people worldwide with a particularly high presence in Africa. Based on recent studies, effective targeting interventions in hotspots could eliminate up to 50% of cases in Sub-Saharan Africa. Those interventions include Water, Sanitation, and Hygiene (WASH) programs whose influence on cholera control, up to the present, has been poorly quantified. Among the few studies available, D'Mello-Guyett et al. underline how the distribution of hygiene kits is a promising form of intervention for cholera control and that the integration of a WASH intervention at the point of admission of suspected cases is new in cholera control efforts, particularly in outbreaks and complex emergencies. Considering the limited number of studies on Community-Led Total Sanitation (CLTS) and water coverages related to cholera control, the aim of our work is to determine whether these interventions in cholera hotspots (geographic areas vulnerable to disease transmission) have significant impact on cholera transmission. In this study, we consider data collected on 125 villages of the Madarounfa district (Niger) during the 2018 cholera outbreak. Using a hurdle model, our findings show that full access to improved sanitation significantly decreases the likelihood of cholera by 91% (P < 0.0001) compared to villages with no access to sanitation at all. Considering only the villages affected by cholera in the studied area, cholera cases decrease by a factor of 4.3 in those villages where there is partial access to at least quality water sources, while full access to improved water sources decreases the cholera cases by a factor of 6.3 when compared to villages without access to water (P < 0.001). In addition, villages without access to safe water and sanitation are 6.7 times (P < 0.0001) more likely to get cholera. Alternatively, villages with full sanitation and water coverage are 9.1 (P < 0.0001) less likely to get cholera. The findings of our study suggest that significant access to improved water and sanitation at the village level offer a strong barrier against cholera transmission. However, it requires full CLTS coverage of the village to observe a strong impact on cholera, as partial access only has a limited impact.

A call for strengthened evidence on targeted, non-pharmaceutical interventions against COVID-19 for the protection of vulnerable individuals in sub-Saharan Africa

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Curbing the transmission of SARS-CoV-2, the causative agent of COVID-19, may be difficult in sub-Saharan Africa.

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Overall COVID-19-related mortality remains low because of the young population.

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Protecting vulnerable individuals from severe disease should be a priority.

Following the easing of lockdown measures in many sub-Saharan African countries, coronavirus disease 2019 (COVID-19) cases have been on the rise. As the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, may be difficult to stop in these settings, we propose that the existing COVID-19 prevention strategies aimed at reducing overall transmission are complemented with more targeted strategies to protect people at risk of severe COVID-19 disease. We suggest investigating the feasibility, acceptability, and efficacy of distributing COVID-19 prevention kits to households with persons at increased risk of severe COVID-19 disease.