Perceptions of Health Communication,Water Treatment and Sanitation in Artibonite Department,Haiti, March-April 2012

The international response to Haiti’s ongoing cholera outbreak has been multifaceted, including health education efforts by community health workers and the distribution of free water treatment products. Artibonite Department was the first region affected by the outbreak. Numerous organizations have been involved in cholera response efforts in Haiti with many focusing on efforts to improve water, sanitation, and hygiene (WASH). Multiple types of water treatment products have been distributed, creating the potential for confusion over correct dosage and water treatment methods. We utilized qualitative methods in Artibonite to determine the population’s response to WASH messages, use and acceptability of water treatment products, and water treatment and sanitation knowledge, attitudes and practices at the household level. We conducted eighteen focus group discussions (FGDs): 17 FGDs were held with community members (nine among females, eight among males); one FGD was held with community health workers. Health messages related to WASH were well-retained, with reported improvements in hand-washing. Community health workers were identified as valued sources of health information. Most participants noted a paucity of water-treatment products. Sanitation, specifically the construction of latrines, was the most commonly identified need. Lack of funds was the primary reason given for not constructing a latrine. The construction and maintenance of potable water and sanitation services is needed to ensure a sustainable change.     

The case for reactive mass oral cholera vaccinations

Introduction

The outbreak of cholera in Zimbabwe intensified interest in the control and prevention of cholera. While there is agreement that safe water, sanitation, and personal hygiene are ideal for the long term control of cholera, there is controversy about the role of newer approaches such as oral cholera vaccines (OCVs). In October 2009 the Strategic Advisory Group of Experts advised the World Health Organization to consider reactive vaccination campaigns in response to large cholera outbreaks. To evaluate the potential benefit of this pivotal change in WHO policy, we used existing data from cholera outbreaks to simulate the number of cholera cases preventable by reactive mass vaccination.

Methods

Datasets of cholera outbreaks from three sites with varying cholera endemicity—Zimbabwe, Kolkata (India), and Zanzibar (Tanzania)—were analysed to estimate the number of cholera cases preventable under differing response times, vaccine coverage, and vaccine doses.

Findings

The large cholera outbreak in Zimbabwe started in mid August 2008 and by July 2009, 98,591 cholera cases had been reported with 4,288 deaths attributed to cholera. If a rapid response had taken place and half of the population had been vaccinated once the first 400 cases had occurred, as many as 34,900 (40%) cholera cases and 1,695 deaths (40%) could have been prevented. In the sites with endemic cholera, Kolkata and Zanzibar, a significant number of cases could have been prevented but the impact would have been less dramatic. A brisk response is required for outbreaks with the majority of cases occurring during the early weeks. Even a delayed response can save a substantial number of cases and deaths in long, drawn-out outbreaks. If circumstances prevent a rapid response there are good reasons to roll out cholera mass vaccination campaigns well into the outbreak. Once a substantial proportion of a population is vaccinated, outbreaks in subsequent years may be reduced if not prevented. A single dose vaccine would be of advantage in short, small outbreaks.

Conclusions

We show that reactive vaccine use can prevent cholera cases and is a rational response to cholera outbreaks in endemic and non-endemic settings. In large and long outbreaks a reactive vaccination with a two-dose vaccine can prevent a substantial proportion of cases. To make mass vaccination campaigns successful, it would be essential to agree when to implement reactive vaccination campaigns and to have a dynamic and determined response team that is familiar with the logistic challenges on standby. Most importantly, the decision makers in donor and recipient countries have to be convinced of the benefit of reactive cholera vaccinations.     

Cholera in the Far East of Russia. Communication 1. Epidemiological characteristics of the outbreak of cholera El tor in Vladivostok

The materials on the investigation of the outbreak cholera eltor in Vladivostok, caused by the import of infection from China. The leading role of the water route of transmission of this infection is shown due to the contamination of water sources with non-decontaminated sewage water. The complex of antiepidemic measures was carried out, which made it possible to arrest the spread of cholera and liquidate its foci.     

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

BackgroundBehavioural 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 findingsWe 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/SignificanceDrinking 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.     

Characterization of Vibrio cholerae cultures isolated in foci of cholera in the city of Kazan

During the period of the registered outbreak of cholera in 2001 in Kazan 171 V. cholerae cultures were isolated in the focus of the infection (from patients, carriers and 7 environmental objects). The use of the basic and additional tests, including the polymerase chain reaction, made it possible to establish the circulation of V. cholerae, phagovar 15, in the focus of the infection. The strain isolated from the water reservoir Azino-1 in Kazan was identical in its properties to the epidemically dangerous strains isolated from patients. On the whole, the data obtained in the identification of the strains showed that the cultures isolated from patients, vibrio-carriers and environmental objects were identical.     

The characteristics of a cholera outbreak in Pushkino District, the Azerbaijan SSR

The outbreak of cholera in the Pushkino District of the Azerbaijan SSR, caused by the penetration of Vibrio cholerae into the water of the irrigation system, is described. Altogether 2 cholera patients and 39 Vibrio carriers were detected. The etiological agent of this infection was V. cholerae eltor, serovar Ogawa, with typical phenotype characteristics. From all patients and 37 carriers virulent strains and from 2 carriers faintly virulent strains were isolated. In this outbreak family foci were clearly observed, but the transmission of infection through everyday contacts was practically of no importance. The foci with multiple cases were formed due to the action of one transmission factor: contaminated water.     

Cholera outbreak in Forcibly Displaced Myanmar National (FDMN) from a small population segment in Cox’s Bazar,Bangladesh, 2019

BackgroundBangladesh experienced a sudden, large influx of forcibly displaced persons from Myanmar in August 2017. A cholera outbreak occurred in the displaced population during September-December 2019. This study aims to describe the epidemiologic characteristics of cholera patients who were hospitalized in diarrhea treatment centers (DTCs) and sought care from settlements of Forcibly Displaced Myanmar Nationals (FDMN) as well as host country nationals during the cholera outbreak.MethodsDiarrhea Treatment Center (DTC) based surveillance was carried out among the FDMN and host population in Teknaf and Leda DTCs hospitalized for cholera during September-December 2019.ResultsDuring the study period, 147 individuals with cholera were hospitalized. The majority, 72% of patients reported to Leda DTC. Nearly 65% sought care from FDMN settlements. About 47% of the cholera individuals were children less than 5 years old and 42% were aged 15 years and more. Half of the cholera patients were females. FDMN often reported from Camp # 26 (45%), followed by Camp # 24 (36%), and Camp # 27 (12%). Eighty-two percent of the cholera patients reported watery diarrhea. Some or severe dehydration was observed in 65% of cholera individuals. Eighty-one percent of people with cholera received pre-packaged ORS at home. About 88% of FDMN cholera patients reported consumption of public tap water. Pit latrine without water seal was often used by FDMN cholera individuals (78%).ConclusionVigilance for cholera patients by routine surveillance, preparedness, and response readiness for surges and oral cholera vaccination campaigns can alleviate the threats of cholera.     

An Optimal Cost Effectiveness Study on Zimbabwe Cholera Seasonal Data from 2008–2011

Incidence of cholera outbreak is a serious issue in underdeveloped and developing countries. In Zimbabwe, after the massive outbreak in 2008–09, cholera cases and deaths are reported every year from some provinces. Substantial number of reported cholera cases in some provinces during and after the epidemic in 2008–09 indicates a plausible presence of seasonality in cholera incidence in those regions. We formulate a compartmental mathematical model with periodic slow-fast transmission rate to study such recurrent occurrences and fitted the model to cumulative cholera cases and deaths for different provinces of Zimbabwe from the beginning of cholera outbreak in 2008–09 to June 2011. Daily and weekly reported cholera incidence data were collected from Zimbabwe epidemiological bulletin, Zimbabwe Daily cholera updates and Office for the Coordination of Humanitarian Affairs Zimbabwe (OCHA, Zimbabwe). For each province, the basic reproduction number () in periodic environment is estimated. To the best of our knowledge, this is probably a pioneering attempt to estimate in periodic environment using real-life data set of cholera epidemic for Zimbabwe. Our estimates of agree with the previous estimate for some provinces but differ significantly for Bulawayo, Mashonaland West, Manicaland, Matabeleland South and Matabeleland North. Seasonal trend in cholera incidence is observed in Harare, Mashonaland West, Mashonaland East, Manicaland and Matabeleland South. Our result suggests that, slow transmission is a dominating factor for cholera transmission in most of these provinces. Our model projects cholera cases and cholera deaths during the end of the epidemic in 2008–09 to January 1, 2012. We also determine an optimal cost-effective control strategy among the four government undertaken interventions namely promoting hand-hygiene & clean water distribution, vaccination, treatment and sanitation for each province.     

Knowledge,Attitudes, and Practices regarding Diarrhea and Cholera following an Oral Cholera Vaccination Campaign in the Solomon Islands

BackgroundIn response to a 2011 cholera outbreak in Papua New Guinea, the Government of the Solomon Islands initiated a cholera prevention program which included cholera disease prevention and treatment messaging, community meetings, and a pre-emptive cholera vaccination campaign targeting 11,000 children aged 1–15 years in selected communities in Choiseul and Western Provinces.ConclusionsThis pre-emptive OCV campaign in a cholera-naïve community provided a unique opportunity to assess household-level knowledge, attitudes, and practices regarding diarrhea, cholera, and water, sanitation, and hygiene (WASH). Our findings suggest that education provided during the vaccination campaign may have reinforced earlier mass messaging about cholera and diarrheal disease in vaccinated communities.     

Use of oral cholera vaccines in an outbreak in Vietnam: a case control study

Background

Killed oral cholera vaccines (OCVs) are available but not used routinely for cholera control except in Vietnam, which produces its own vaccine. In 2007–2008, unprecedented cholera outbreaks occurred in the capital, Hanoi, prompting immunization in two districts. In an outbreak investigation, we assessed the effectiveness of killed OCV use after a cholera outbreak began.

Methodology/Principal Findings

From 16 to 28 January 2008, vaccination campaigns with the Vietnamese killed OCV were held in two districts of Hanoi. No cholera cases were detected from 5 February to 4 March 2008, after which cases were again identified. Beginning 8 April 2008, residents of four districts of Hanoi admitted to one of five hospitals for acute diarrhea with onset after 5 March 2008 were recruited for a matched, hospital-based, case-control outbreak investigation. Cases were matched by hospital, admission date, district, gender, and age to controls admitted for non-diarrheal conditions. Subjects from the two vaccinated districts were evaluated to determine vaccine effectiveness. 54 case-control pairs from the vaccinated districts were included in the analysis. There were 8 (15%) and 16 (30%) vaccine recipients among cases and controls, respectively. The vaccine was 76% protective against cholera in this setting (95% CI 5% to 94%, P = 0.042) after adjusting for intake of dog meat or raw vegetables and not drinking boiled or bottled water most of the time.

Conclusions/Significance

This is the first study to explore the effectiveness of the reactive use of killed OCVs during a cholera outbreak. Our findings suggest that killed OCVs may have a role in controlling cholera outbreaks.     

Cholera caused by Vibrio cholerae O1 ctxAB- tcpA+

Results of analysis of cholera outbreak during which V. cholerae O1 biovar El-Tor ctxAB- tcpA+ was isolated from 2 patients and 30 carriers are presented. Epidemic was caused by contamination of water source and water route of transmission. Strains identical to ones detected in humans were isolated from water of surface well in zone of water intake. Genome and VNTR-analysis of ctxAB- tcpA+ vibrios that caused outbreak in Rostov region in 2005 showed that they differed from ctxAB- tcpA- and ctxAB- tcpA+ vibrios isolated previously during and beyond of outbreaks from patients, carriers and environment and formed separate group with certain genotype. These results confirms conclusions of epidemiological analysis about imported cause of recent outbreak.     

Characterization of Vibrio cholerae eltor in the city of Kazan in 2001

Information on V. cholerae eltor isolated in the focus of cholera in Kazan in 2001 at different periods of the outbreak is presented. The identity of strains isolated from patients, vibriocarriers and environmental objects, including their antibioticograms (sensitivity to cyprofloxacin and resistance to trimethoprim--sulfamethoxazole, streptomycin, furazolidone and nalidixic acid, which may be regarded as markers), is shown. Variable tandem repetitions in the DNA of 30 isolates strains of different origin have been determined. The results of this determination make it possible to classify all these strains as one genotype, which confirms the suggestion on the circulation of one subclone of the infective agent of cholera in the focus. As revealed in this investigation, the isolated strains are labile with respect to diagnostic phage eltor, while ctx+ strains are resistant to phage eltor ctx+.     

An outbreak of cholera (El Tor) in Samarkand Province, Uzbekistan in 1990]

A group outbreak of cholera caused by Vibrio eltor in the Samarkand Province++ in 1990 is analyzed. The retrospective analysis of the isolation of V. cholerae from water of surface reservoirs has been made. The study points out that since the cholera epidemic of 1985 V. cholerae avirulent strains, serogroup O1, have been periodically isolated in the Samarkand Province. The conclusion has been made that the isolation of even avirulent strains only from environmental objects is indicative of the unfavorable epidemiological situation in this area and of the necessity to take measures for improving epidemiological surveillance.     

Risk Map of Cholera Infection for Vaccine Deployment: The Eastern Kolkata Case

Background

Despite advancement of our knowledge, cholera remains a public health concern. During March-April 2010, a large cholera outbreak afflicted the eastern part of Kolkata, India. The quantification of importance of socio-environmental factors in the risk of cholera, and the calculation of the risk is fundamental for deploying vaccination strategies. Here we investigate socio-environmental characteristics between high and low risk areas as well as the potential impact of vaccination on the spatial occurrence of the disease.

Methods and Findings

The study area comprised three wards of Kolkata Municipal Corporation. A mass cholera vaccination campaign was conducted in mid-2006 as the part of a clinical trial. Cholera cases and data of the trial to identify high risk areas for cholera were analyzed. We used a generalized additive model (GAM) to detect risk areas, and to evaluate the importance of socio-environmental characteristics between high and low risk areas. During the one-year pre-vaccination and two-year post-vaccination periods, 95 and 183 cholera cases were detected in 111,882 and 121,827 study participants, respectively. The GAM model predicts that high risk areas in the west part of the study area where the outbreak largely occurred. High risk areas in both periods were characterized by poor people, use of unsafe water, and proximity to canals used as the main drainage for rain and waste water. Cholera vaccine uptake was significantly lower in the high risk areas compared to low risk areas.

Conclusion

The study shows that even a parsimonious model like GAM predicts high risk areas where cholera outbreaks largely occurred. This is useful for indicating where interventions would be effective in controlling the disease risk. Data showed that vaccination decreased the risk of infection. Overall, the GAM-based risk map is useful for policymakers, especially those from countries where cholera remains to be endemic with periodic outbreaks.     

Cholera Threat to Humans in Ghana Is Influenced by Both Global and Regional Climatic Variability

Cholera, an acute diarrheal illness, is caused by infection of the intestine with the bacterium Vibrio cholerae after ingestion of contaminated water or food. The disease had disappeared from most of the developed countries in the last 50 years, but cholera epidemics remain a major public health problem in many developing countries, most often localized in tropical areas. Cholera is an infectious disease for which a relationship between disease temporal patterns and climate has been demonstrated, but only in an endemic context and for local areas of Asia and South America. Until now, similar studies have not been done in an epidemic context, on the African continent, although the largest number of cholera cases has been reported for those countries by the World Health Organization. The wavelet method was used in order to explore periodicity in (i) a long-time monthly cholera incidence in Ghana, West Africa, (ii) proxy environmental variables, and (iii) climatic indices time series, from 1975 to 1995. Cross-analysis were done to explore links between these time series, i.e., between cholera and climate. Results showed strong statistical association (coherency) from the end of the 1980s, between cholera outbreak resurgences in Ghana and the climatic/environmental parameters under scrutiny. Further examination of the existence of common spatial and temporal patterns in infectious diseases on the continent of Africa will permit development of more effective treatment of disease.     

Cholera in the Far East of Russia. Communication 2. Epidemiological characteristics of the outbreak of cholera El tor in Iuzhno-Sakhalinsk

The outbreak of cholera eltor in Yuzhno-Sakhalinsk has been analyzed. The fact of the import of this infection from China and its transmission mainly by the water route due to the intensive contamination of environmental objects has been substantiated. The effective purification decontamination of sewage water plays decisive role on the system of anticholera measures. The conclusion on the necessity of increasing the effectiveness of measures for the sanitary protection of the territory has been made.     

Demonstration of viable but nonculturable Vibrio cholerae O1 in fresh water environment of India using ciprofloxacin DFA-DVC method

Aim: To demonstrate the presence of culturable and nonculturable viable pathogenic Vibrio cholerae O1 in fresh water environments of a cholera‐endemic region in India. Methods and Results: Conventional culture and ciprofloxacin DFA–DVC were utilized to investigate the existence of V. cholerae O1. We isolated pathogenic culturable V. cholerae O1 from water samples collected from cholera‐affected areas. No culturable V. cholerae O1 was isolated from water and plankton samples from natural fresh water bodies. Ciprofloxacin was used for DFA–DVC as V. cholerae O1 are 100% resistant to nalidixic acid in our region. The viable but nonculturable O1 cells were demonstrated in 2·21 and 40·69% samples from natural water bodies and cholera‐affected areas, respectively. Conclusion: Vibrio cholerae O1 VBNC could be demonstrated using modified DFA–DVC technique. Ciprofloxacin is preferable to nalidixic acid for DVC in view of existing high‐level resistance to nalidixic acid in cholera‐endemic areas. Significance and Impact of the study: We endorse that for public health surveillance, cholera outbreak investigation and disease control water samples in addition to culture should be tested for V. cholerae using DFA–DVC.     

Comparison of automated ribotyping and pulsed-field gel electrophoresis for subtyping of Vibrio cholerae

Aims:  To compare the discriminatory power of an automated ribotyping method for Vibrio cholerae subtyping with the pulsed-field gel electrophoresis (PFGE), to evaluate the possibility of automated ribotyping in use of outbreak investigations and surveillance of cholera.
Methods and Results:  Eight-one epidemiologically unrelated isolates of V. cholerae , and 19 isolates from seven cholera outbreaks were used as the panels. When comparing the two methods using the epidemiologically unrelated isolates, automated ribotyping using Pvu II distinguished 38 different ribotypes with a D -value of 0·8956. When combined with serotyping, the D -value is 0·9466. However, PFGE with Not I and Sfi I digestions had higher D -values of 0·9951 and 0·9948, respectively. PFGE could cluster the isolates from each outbreak into the same pattern, and distinguish different patterns from different outbreaks, whereas automated ribotyping had lower discriminatory ability.
Conclusions:  The automated ribotyping has lower discriminatory ability compared to PFGE, and is limited to application in V. cholerae subtyping and outbreak investigation.
Significance and Impact of the Study:  The study evaluated the limitation in subtyping of automated ribotyping for V. cholerae , and raise the question of improvement for the automated ribotyping in subtyping.     

Cholera Transmission in Ouest Department of Haiti: Dynamic Modeling and the Future of the Epidemic

In the current study, a comprehensive, data driven, mathematical model for cholera transmission in Haiti is presented. Along with the inclusion of short cycle human-to-human transmission and long cycle human-to-environment and environment-to-human transmission, this novel dynamic model incorporates both the reported cholera incidence and remote sensing data from the Ouest Department of Haiti between 2010 to 2014. The model has separate compartments for infectious individuals that include different levels of infectivity to reflect the distribution of symptomatic and asymptomatic cases in the population. The environmental compartment, which serves as a source of exposure to toxigenic V. cholerae, is also modeled separately based on the biology of causative bacterium, the shedding of V. cholerae O1 by humans into the environment, as well as the effects of precipitation and water temperature on the concentration and survival of V. cholerae in aquatic reservoirs. Although the number of reported cholera cases has declined compared to the initial outbreak in 2010, the increase in the number of susceptible population members and the presence of toxigenic V. cholerae in the environment estimated by the model indicate that without further improvements to drinking water and sanitation infrastructures, intermittent cholera outbreaks are likely to continue in Haiti.     

The impact of spatial arrangements on epidemic disease dynamics and intervention strategies

The role of spatial arrangements on the spread and management strategies of a cholera epidemic is investigated. We consider the effect of human and pathogen movement on optimal vaccination strategies. A metapopulation model is used, incorporating a susceptible–infected–recovered system of differential equations coupled with an equation modelling the concentration of Vibrio cholerae in an aquatic reservoir. The model compared spatial arrangements and varying scenarios to draw conclusions on how to effectively manage outbreaks. The work is motivated by the 2010 cholera outbreak in Haiti. Results give guidance for vaccination strategies in response to an outbreak.