Research proposal on cholera

IGERT Research Proposal

CHOLERA PREVENTION AND CONTROL IN KENYA Gretchen A

thus, remote or lack of access to safe drinking water in some of the limited areas located in lakeshore cities appears to be the primary cause of cholera outbreaks., therefore, decided to develop research work intended to facilitate the understanding of the epidemiology of cholera in eastern drc and to disseminate the acquired knowledge so as to ensure an improvement of the strategy for continuing the fight against cholera. study in rural guinea bissau during the 1994 cholera outbreak explored local views about cholera and the diffusion of health messages, and assessed whether the messages contributed to behaviour change [28]. cholera outbreak in southern tanzania: risk factors and patterns of transmission. study conducted in the philippines attempted to evaluate the impact of improvements to wash infrastructure on cholera incidence by comparing a control community with communities with: i) safe water supply, ii) shared toilet facilities, and iii) both water supply and shared toilet facilities [33]. no significant difference in cholera incidence between intervention and control groups was found for those aged over five years. this action may have paradoxically increased their risk of cholera, and the paper concluded that the intervention was an ineffective, costly and impractical method of water treatment and should be discouraged. guidelines for the preferred reporting items for systematic reviews and meta-analyses (prisma) were used to conduct a systematic search for original research of the impact of wash interventions implemented to control cholera in a low, or middle income country [9]. despite these programs, no significant progress has been registered in the fight against cholera in this region. sources of cholera information in urban areas were radio (71%), tv (64%) and group health talks (50%) compared to rural areas where health workers (70%), government authorities (61%) and radio (58%) were the most common. cholera evolution in kalemie city (from 2002 to 2007, weekly number of cases). indeed, the epidemiological studies have outlined the link between the living conditions of these fishermen and the emergence and the dissemination of cholera epidemics.: seasonality of cholera from 1974 to 2005: a review of global patterns, int. in both cases, the recurrent actions should be warranted by their expected fallouts on the reduction of cholera epidemics. bacteriological surveillance of confirmed cholera, conducted from 1968–1972 suggested that cholera incidence could be reduced by 68%, 73%, and 76%, by implementing low cost sanitation, water supply or both, respectively.: cholera outbreak in southern tanzania: risk factors and patterns of transmission, emerg. plos one 10(8):Introductioncholera is a diarrhoeal disease caused by infection with the bacteria vibrio cholera. such reactive posture, even though it greatly limited the number of deaths when promptly and correctly applied, could not achieve a control of the cholera epidemics. cholerae tends to favour slightly brackish to saline water, temperatures of up to 30°c and association with algae, zooplankton and copepods tends to promote its survival and pathogenicity [39]. in order to eliminate cholera in the drc, 7 strategic adjustments have been determined:Empowerment of the activities of epidemiological surveillance. consequently, available human and financial resources are easier to gather on a few sites to hopefully tackle cholera until its complete elimination from the eastern region of the drc. it was then possible to determine a scale in the cholera dissemination, pointing out the role of “sanctuary” played by some suburbs of lakeshore cities. the questions emerging from the cholera project will go through real-time analysis by the “direction de la lutte contre la maladie” (branch of the congolese public health ministry dedicated to fight epidemics) with the technical support of an international network of universities and the financial support from different stakeholders. cholerae o1 cholera in a fishing village near karachi, pakistan. all previously selected households were visited within six weeks of the outbreak, and local criteria for case definition were used to identify cholera cases. while european research workers accompany them with their experience and methodology, they benefit from a network of very efficient and reactive collectors of epidemiological information, which enables them to produce an excellent tool in order to follow the real-time evolution of cholera and to establish modelled risk patterns. according to official reports, cholera was responsible for 902 071 new cases and 21 417 deaths during the last six years (who, 2003, 2004, 2005, 2006, 2007, 2008).. to summarize, from 2002 to 2005, reports of cholera cases and deaths from cholera were collected weekly from each health district of katanga and eastern kasai provinces. presence of vibrio cholerae was confirmed in bacteriological tests in participants for up to 5 days after identification of the index case. trial carried out in an endemic setting in india, randomised family contacts of 91 hospital admitted cholera patients to a study arm that received either: chlorine tablets (1. active unit has slowly built up associating individuals originating from diverse horizons: doctors and field actors working for the public health ministry in kinshasa and other vulnerable cholera zones, scientists based in france and belgium, the general delegate of a private foundation and several water engineers related to ngos or private firms. however, except for an epidemic that hit kinshasa in the late nineties, large cholera outbreaks only occur in the provinces situated on the eastern continental border of the drc, namely katanga, south kivu, north kivu, and the oriental province.

Conducting Research in Disease Outbreaks

these ‘water quality’ conditions tend not to prevail in well water, and wells are not considered reservoirs for cholera. the basic assumption about cholera was not contradicted for decades: it was simply the disease associated with misery and one could not prevent the epidemics except to counter the outbreaks when they reached a certain intensity. most recent study evaluated the response to the haiti cholera epidemic in 2010, where the government and other agencies implemented a free mass distribution of various chlorine products alongside hygiene promotion activities in a rural setting [26]. experimental, observational and qualitative studies were considered for inclusion when they clearly described a cholera outbreak or endemic setting and were published in peer-reviewed journals. in countries bordering the bay of bengal, the original region of cholera, outbreaks are closely linked to costal and estuary areas., a collaborative network, including several scientific institutions in europe and in the drc, local and national government administrations in the field of public health and sanitation, international agencies, ngos and private foundations, was progressively set up and a new plan was drawn up, aiming to eliminate cholera from the drc before 2012. the targeted zones for this activity consists of the previously mentioned regions as well as a few nearby-located great urban centres (lubumbashi, likasi, kolwezi, kamina in katanga and mbuji-mayi in oriental kasaï) where the data analysis stressed their vulnerability to cholera. the study reported that 94% of 53 interviewees had heard, or seen a cholera prevention message, and that 68% of those, recalled at least one preventative method. furthermore, epidemiological investigations have reported a protective effect of hand washing when food was associated in cholera outbreaks, as well as in outbreaks where the source remained unidentified [46–48]. a recent paper reviewing promed (program for monitoring emerging disease) reports of cholera outbreaks worldwide showed that sub-saharan africa is now the most affected region with 66% of reported outbreaks and 87. several joint missions of medical specialists in epidemiology of cholera and engineers in water and sanitation in eastern drc have confirmed that there was a need for drastic improvement of water and sanitation infrastructures, especially in these urban and suburban areas.: a 4-year study of the epidemiology of vibrio cholerae in four rural areas of bangladesh, j. the strategy presented here, as it is strongly supported by the results of scientific research and as it is targeted to be implemented in a short time, definitely revives the hope to eliminate cholera in the drc. while 70% of the respondents would consume boiled water, or water with lemon juice added to it, not a single person could explain the transmission of cholera. the results of this much needed operational research will be invaluable to informing international wash policy, standards and practice with the ultimate aim being, to contribute to reducing the global burden of cholera. each time an outbreak strikes one of the main towns in southern katanga or in eastern kasa¨ı, namely lubumbashi, kolwezi, likasi, or mbuji-mayi, local medical staffwere reinforced by humanitarian organizations to set up centres for cholera treatment and to implement public awareness and information campaigns. on the contrary, due to these iterative outbreaks that hit katanga and kivu provinces, the drc is nowadays the country that reports the highest number of cholera cases in the world to who. epidemic cholera in urban zambia: hand soap and dried fish as protective factors.: epidemic cholera in burundi: patterns of transmission in the great rift valley lake region, lancet, 349(9057), 981–985, 1997. it was then possible to determine a scale in the cholera dissemination, pointing out the role of “sanctuary” played by some suburbs of lakeshore cities. cholera evolution in kalemie city (from 2002 to 2007, weekly number of cases). each time an outbreak strikes one of the main towns in southern katanga or in eastern kasa¨ı, namely lubumbashi, kolwezi, likasi, or mbuji-mayi, local medical staffwere reinforced by humanitarian organizations to set up centres for cholera treatment and to implement public awareness and information campaigns. it plays a key role in the durability of the cholera pandemics in this region. finally, it was expected that a strategy against cholera based on access to safe drinking water and good medical surveillance in those areas could eliminate the epidemics of cholera in eastern drc. there is a distinct gap in knowledge of which interventions are most appropriate for a given context and as such a clear need for more robust impact studies evaluating a wider array of wash interventions, in order to ensure effective cholera control and the best use of limited resources. lakes as source of cholera outbreaks, democratic republic of congo., 2007) but they were not designed to provide policy makers the skills and knowledge needed to organize more efficiently the fight against cholera. the drc, the area of the provinces hit by cholera is equal to the size of france, spain and portugal together. intra-familial transmission of vibrio cholerae biotype el tor in calcutta slums. the study found that 93% of rural, and 67% of urban respondents believed they could prevent cholera transmission. in countries bordering the bay of bengal, the original region of cholera, outbreaks are closely linked to costal and estuary areas. this broad study enabled us to accurately determine the cholera epidemic’s mechanisms on different scales; to identify the source zones of the disease, and the groups of populations acting as vectors of the spread.

Proposal for funding WHO emergency operations in Zimbabwe pdf

however, the odds of cholera in those <5 years were 88% lower in the sodis group when compared to the control group (p = 0. cholerae and have been implicated in past outbreaks of cholera [36–38]. consequently cholera epidemics require the same interventions used to prevent and control diarrhoeal diseases. factors that could explain the recurrence of cholera outbreaks were investigated during an epidemiological study which involved all cases of cholera notified in the drc since 2002. democratic republic of congo (drc) is the country in the world which reported the highest number of cholera cases to who from 2002 to 2007 (128 936 cases out of a worldwide 902 071 cases). The strategy presented here revives the hope to eliminate cholera in the DRC. the 7 targeted health zones according to the strategic plan of cholera elimination in the drc. this contrasts with asia, where monitoring programs benefit from a comprehensive knowledge of cholera epidemiology., 2007) but they were not designed to provide policy makers the skills and knowledge needed to organize more efficiently the fight against cholera. however, the project can already be considered meaningful in it’s progress in the fight against cholera on the african continent simply because the very idea of eliminating this epidemic disease has been brought forward. the revival of the fight against cholera originates from the above described epidemiological studies. in light of this evidence we would not recommend well chlorination as a measure to control cholera. despite these programs, no significant progress has been registered in the fight against cholera in this region. the 7 targeted health zones according to the strategic plan of cholera elimination in the drc. it plays a key role in the durability of the cholera pandemics in this region.: climate and cholera in kwazulu-natal, south africa: the role of environmental factors and implications for epidemic preparedness, int. indeed, the epidemiological studies have outlined the link between the living conditions of these fishermen and the emergence and the dissemination of cholera epidemics. primary objective of this review was to identify and assess the evidence for the effectiveness of wash interventions to control cholera, and provide recommendations to implementers during cholera outbreaks, while a secondary objective was to highlight the gaps in knowledge and identify areas for further research. Democratic Republic of Congo (DRC) is the country in the world which reported the highest number of cholera cases to WHO from 2002 to 2007 (128 936 cases out of a worldwide 902 071 cases).: climate and cholera in kwazulu-natal, south africa: the role of environmental factors and implications for epidemic preparedness, int. the clinical care of cholera sufferers will continue to be based on rehydration at the treatment centres for diarrhoeal diseases. more specifically, cholera will be considered eliminated once the annual incidence rate is below 1 case out of 100 000 inhabitants; in other words, less than 500 new cases per year (nowadays, the incidence is on average 270 cases out of 100 000 inhabitants for the whole country). recent study measured the uptake of household disinfection kits as an additional prevention method in the haiti cholera outbreak [32]. democratic republic of congo (drc) is the country in the world which reported the highest number of cholera cases to who from 2002 to 2007 (128 936 cases out of a worldwide 902 071 cases). such a large surface could represent a major obstacle for any participant wanting to protect the congolese population from cholera. several joint missions of medical specialists in epidemiology of cholera and engineers in water and sanitation in eastern drc have confirmed that there was a need for drastic improvement of water and sanitation infrastructures, especially in these urban and suburban areas., this epidemiological study also pointed out the inadequacy of the past strategy used to fight cholera in the drc, which was based upon classical reactive posture in emergency situations. since the great cholera epidemic in refugees camps in kivu provinces in 1994, which led to the publication of a few reports, this topic has been totally left out by the medical and scientific community (heyman et al. active unit has slowly built up associating individuals originating from diverse horizons: doctors and field actors working for the public health ministry in kinshasa and other vulnerable cholera zones, scientists based in france and belgium, the general delegate of a private foundation and several water engineers related to ngos or private firms. using regression techniques, we statistically examined the relationship between the number of cholera cases in each health district and the following list of geographic and environmental variables: area; population; presence of cities whose population ran over 100 000 inhabitants; means of transportation such as railway stations, harbours, major tracks or roads; and lakes. cholera evolution in kalemie city (from 2002 to 2007, weekly number of cases). reductions that meta-analysis have shown can be achieved, speak in support of hwws as a cholera prevention measure, but more research and evaluation are needed to confirm its effectiveness.

CHOLERA PREVENTION AND CONTROL IN KENYA Gretchen A

The Impact of Water, Sanitation and Hygiene Interventions to Control

: critical factors influencing the occurrence of vibrio cholerae in the environment of bangladesh, appl. cholera evolution in kalemie city (from 2002 to 2007, weekly number of cases). moreover, the ministry of public health of the drc has set the goal of total “elimination” of cholera approaching 2012.: lakes as source of cholera outbreaks, democratic republic of congo, emerg.’s reinforcement the stakeholders involved in the fight against cholera will be gathered on a communication/coordination platform where the exchange of information and of funding will be centralised for a unified action. simple sari cloth filtration of water is sustainable and continues to protect villagers from cholera in matlab, bangladesh. exactly the same problem will arise when the accumulated knowledge in the drc will have to be transferred to another country hit by cholera epidemics.: epidemic cholera in burundi: patterns of transmission in the great rift valley lake region, lancet, 349(9057), 981–985, 1997. collaboration, cholera, and cyclones: a project to improve point-of-use water quality in madagascar. surprisingly, the dynamics of cholera transmission has almost never been investigated in africa. surprisingly, the dynamics of cholera transmission has almost never been investigated in africa., our deepest thanks goes to: the contributors attending the 17 and 18 december 2007 in kinshasa, the workshop on the adoption of the strategic plan for the elimination of cholera in drc; to philippe barragne-bigot and to the drc unicef for the promotion of the plan for cholera elimination and their support for the publication of the “bulletin du projet d’elimination du choléra en rdc (belichol).: why treatment centres failed to prevent cholera deaths among rwandan refugees in goma, zaire, lancet, 345(8946), 359–361, 1995. study conducted among the maasai in kenya evaluated the impact of solar disinfection (sodis) using the number of self-reported cholera cases over a three month period following an outbreak [20]. the 7 targeted health zones according to the strategic plan of cholera elimination in the drc. this broad study enabled them to accurately determine the mechanisms of the cholera epidemics on different scales, to identify the source zones of the disease, and the groups of populations acting as vectors of the spread. there is likely to be a wealth of useful information available in operational and evaluation reports by non-governmental organisations (ngos) working in emergencies and cholera outbreaks, however it is unclear how much is available as not all is in the public domain, while some might contain sensitive information that ngos are unwilling to share.: cholera outbreak in southern tanzania: risk factors and patterns of transmission, emerg. since the great cholera epidemic in refugees camps in kivu provinces in 1994, which led to the publication of a few reports, this topic has been totally left out by the medical and scientific community (heyman et al. the world health organisation (who) estimates that there are between 3–5 million cholera cases and 100,000–120,000 deaths every year, of which only a fraction are officially reported [1]. the key inclusion criteria were: i) a clearly defined wash intervention, ii) a cholera health outcome, or data pertaining to the function and use of the wash intervention. in both cases, the recurrent actions should be warranted by their expected fallouts on the reduction of cholera epidemics. a programme in antananarivo, madagascar implemented in response to a major cholera outbreak, used community mobilisation and social marketing of a locally produced 0.’s reinforcement the stakeholders involved in the fight against cholera will be gathered on a communication/coordination platform where the exchange of information and of funding will be centralised for a unified action. indeed, since its introduction in conacry in 1970, cholera has spread all over sub-saharan africa and still provokes epidemics, despite hundreds of emergency programs implemented by ngos. this research will focus on cholera but there will be additional external benefits to be gained in the reduction of diarrhoeal diseases. an extensive review of epidemiological data of cholera outbreaks in india, bangladesh and the philippines in the 1980s, found that 35–80% of cholera infection in the contacts of index cases occurred after more than 2 days, thereby suggesting that these contacts were infected by person-to-person transmission within the family [35]. likewise, the epidemiological arguments and their suitability with the national scheme for the elimination of cholera can be both a real asset in the search for funds in the sphere of sustainable development as well as for emergency answers. light of the abundance of evidence supporting the promotion of hand washing to reduce diarrhoeal disease, and since the same wash interventions apply to cholera it is surprising that so few studies specifically evaluate hwws to prevent cholera. the preferred method of communication of those receiving cholera messages was tv (71%) and radio (69%)., 1999), most available reports only describe cholera outbreaks in a given area such as a town or a refugee settlement. such reactive posture, even though it greatly limited the number of deaths when promptly and correctly applied, could not achieve a control of the cholera epidemics.

The Cholera Epidemic and Barriers to Healthy Hygiene and

, 1999), most available reports only describe cholera outbreaks in a given area such as a town or a refugee settlement. to this end, we recommend that future research proposals are designed to be implemented as soon as an outbreak response is initiated. the main reasons for exclusion were; no clearly defined wash intervention (34), not related to cholera (9), or not peer-reviewed (2). however, except for an epidemic that hit kinshasa in the late nineties, large cholera outbreaks only occur in the provinces situated on the eastern continental border of the drc, namely katanga, south kivu, north kivu, and the oriental province. in this town, cholera never stopped for more than 6 years (fig. influence of water temperature, salinity, and ph on survival and growth of toxigenic vibrio cholerae serovar 01 associated with live copepods in laboratory microcosms. indeed, the heterogeneity of cholera epidemic patterns from one area to another matches their main geographical characteristics: lacustrine areas have been more severely hit (fig. we truly thank the members of the “cholera team in drc” that have been working for the last 2 years in the scope of the epidemiological surveillance which encompasses anthropologic, socio-economic and environmental aspects (annie mutombo and berthe miwanda in kinshasa; armand luhembwe mutadi, mulungu mpemba, tampon kibuku in kalemie). access to safe water in rural artibonite, haiti 16 months after the onset of the cholera epidemic. in africa, a similar phenomenon could possibly explain some of the outbreaks of cholera spreading from coastal areas, but it hardly explains how the disease can hit areas located thousands of kilometres away from the coast. the periodic return of fishermen to their home in the lakeside cities, acts as a trigger for cholera outbreaks. hence hwt systems, as they focus exclusively on transmission via drinking water, are not by themselves, suitable interventions in every cholera outbreak and should not be employed as a universal remedy. The strategy presented here revives the hope to eliminate cholera in the DRC.: a 4-year study of the epidemiology of vibrio cholerae in four rural areas of bangladesh, j.. we would like to acknowledge and extend our heartfelt gratitude to the following persons and entities that have made the completion of this article possible: the public health ministry of the drc, the congolese medical teams of the provinces of katanga, south kivu, north kivu, and the oriental and maniema province, to the researchers of the university of franche-comté (patrick giraudoux, martine piarroux, bertrand sudre) still involved in the cholera research. since this period, more than one hundred cholera outbreaks have been investigated, most of them in katanga, south and north kivu provinces, and dozens of emergency programs have been implemented. this situation led to a paradox: for a majority of aid workers dealing with public health, cholera outbreaks were trivialized in kalemie and other lakeside cities of katanga due to high frequency of occurrence, when a few cases in the main cities of south katanga were enough to alarm the public because cholera was not striking there every year. ), a screening of the organisation of the local water board, a mapping of the ongoing activities from the pool of participants involved in the global enhancement of the supply of safe drinking water focusing on their impact on the fight against cholera. ), a screening of the organisation of the local water board, a mapping of the ongoing activities from the pool of participants involved in the global enhancement of the supply of safe drinking water focusing on their impact on the fight against cholera. factors that could explain the recurrence of cholera outbreaks were investigated during an epidemiological study which involved all cases of cholera notified in the drc since 2002. the strategy presented here, as it is strongly supported by the results of scientific research and as it is targeted to be implemented in a short time, definitely revives the hope to eliminate cholera in the drc. We, therefore, implemented research work which intends to understand the epidemiology of cholera in the DRC and to ensure improvements in the strategy to fight against cholera. we present here a brief overview of the development of our project from the initial scientific results to the first steps of the ongoing field work in the main cholera foci of eastern drc. studies, conducted by the 4th direction of the congolese ministry of health and a north-south university network, clearly pointed out the role of seven cities located on the lake’s shore that act as the main source of cholera epidemics, namely bukama, bukavu, bunia, goma, kalemie, kasenga and uvira. this myth is now vanishing with the results showing that epidemics only originate in lakeshore regions where targeted actions on water supply are reducing cholera epidemics. conducted a knowledge, attitudes and practice survey in urban and rural amazon communities, to assess the impact of a nationwide prevention campaign, 6 months after the beginning of the peruvian cholera epidemic in 1991 [30]. for example 88% of the urban group and 92% of the rural group knew that drinking treated water was a cholera prevention method but only 25% and 23% respectively, always practised this. we truly thank the members of the “cholera team in drc” that have been working for the last 2 years in the scope of the epidemiological surveillance which encompasses anthropologic, socio-economic and environmental aspects (annie mutombo and berthe miwanda in kinshasa; armand luhembwe mutadi, mulungu mpemba, tampon kibuku in kalemie). these lessons should be applied to future cholera interventions with more rigorous evaluation. the 7 targeted health zones according to the strategic plan of cholera elimination in the drc. this contrasts with asia, where monitoring programs benefit from a comprehensive knowledge of cholera epidemiology. in these areas, contaminated surface water (mainly lakes) used by thousands of people for drinking or for personal hygiene is obviously the source of cholera epidemics (fig.

From research to field action: example of the fight against cholera in

a large cholera outbreak in kano city, nigeria: the importance of hand washing with soap and the danger of street-vended water. Democratic Republic of Congo (DRC) is the country in the world which reported the highest number of cholera cases to WHO from 2002 to 2007 (128 936 cases out of a worldwide 902 071 cases). a single study in an endemic setting compared a combination of interventions to improve water and sanitation infrastructure, and the resulting reductions in cholera incidence. :epidemics, democratic republic of congo, sanitation, water supply, choleratop of page. main concepts; water supply, water quality, sanitation and hygiene, were searched in combination with cholera and associated synonyms of acute watery diarrhoea, and with low or middle income countries as defined by the world bank. this new comprehensive strategy was discussed during a workshop gathering the main stakeholders held from 17 to 18 december 2007 in kinshasa and further formalized in the strategic plan for the elimination of cholera in the drc 2008–2012 approved by the minister of health of drc. if the epidemiological supervision shows that cholera is receding from katanga since the first 2008 quarter, it is obvious that the fight against cholera has just begun and that extensive work on safe water supply is to be expected. exactly the same problem will arise when the accumulated knowledge in the drc will have to be transferred to another country hit by cholera epidemics. well chlorination using liquid bleach was assessed following its implementation during the 2008 cholera outbreak in guinea-bissau [15]. results of the trial suggested that cholera incidence was reduced by 48% in the sari filter group (p<0., a collaborative network, including several scientific institutions in europe and in the drc, local and national government administrations in the field of public health and sanitation, international agencies, ngos and private foundations, was progressively set up and a new plan was drawn up, aiming to eliminate cholera from the drc before 2012.: why treatment centres failed to prevent cholera deaths among rwandan refugees in goma, zaire, lancet, 345(8946), 359–361, 1995. this situation led to a paradox: for a majority of aid workers dealing with public health, cholera outbreaks were trivialized in kalemie and other lakeside cities of katanga due to high frequency of occurrence, when a few cases in the main cities of south katanga were enough to alarm the public because cholera was not striking there every year. we present here a brief overview of the development of our project from the initial scientific results to the first steps of the ongoing field work in the main cholera foci of eastern drc. cholera outbreak in kenyan refugee camp: risk factors for illness and importance of sanitation. this seems to highlight the generally held belief that cholera is exclusively waterborne, thereby ignoring other routes of transmission. indeed, identifying the particular foci that act as the source of cholera epidemics on the whole continent and establishing a map of high risks areas, is an indispensable prerequisite before implementing a program targeting cholera in africa. further results show that the control group had better knowledge of the main cholera transmission routes than the intervention group, but these were not discussed. plan for the elimination of cholera is now drawn up and ratified. reported that 99% of 442 respondents in 16 villages exposed to a cholera education programme in zambia showed awareness of cholera compared to 92% of 131 respondents in two control villages in a different district, however no test of significance was reported [29]. the strategy presented here revives the hope to eliminate cholera in the drc. a recent paper reviewing promed (program for monitoring emerging disease) reports of cholera outbreaks worldwide showed that sub-saharan africa is now the most affected region with 66% of reported outbreaks and 87. revealed an original epidemiological pattern of cholera, distinct from those described in coastal areas, with specific sources in lacustrine areas, transmission pathways by main roads and railways and seasonal variations related to fishing and commercial activities. who experts estimate that the true burden of cholera is as high as 5. such a large surface could represent a major obstacle for any participant wanting to protect the congolese population from cholera. we, therefore, implemented research work which intends to understand the epidemiology of cholera in the drc and to ensure improvements in the strategy to fight against cholera. countries hit by cholera are not so numerous, even in africa (in 2007, among the 34 african countries which have declared cases of cholera to who, only 17 had more than one thousand cases (who, 2008) and among them, the drc was one of the hardest places to implement such a study, regarding the immensity of its territory, the difficulties to collect data in remote areas and the conflict in the eastern part of the country. there is without doubt a great need for studies evaluating cholera response interventions, in the spirit of the who minimum evaluation procedure [34]. finally, it was expected that a strategy against cholera based on access to safe drinking water and good medical surveillance in those areas could eliminate the epidemics of cholera in eastern drc. however, john snow’s conviction that hand washing with soap could dramatically slow down, or even stop the rapid outbreak of cholera epidemics [35] is often forgotten. We, therefore, implemented research work which intends to understand the epidemiology of cholera in the DRC and to ensure improvements in the strategy to fight against cholera. the practice of sending spraying teams to disinfect houses of cholera patients is now discouraged as there is no evidence that one-off disinfection has any impact on transmission.

Conducting Research in Disease Outbreaks

KNOWLEDGE, ATTITUDE AND PRACTICE OF CHOLERA

the basic assumption about cholera was not contradicted for decades: it was simply the disease associated with misery and one could not prevent the epidemics except to counter the outbreaks when they reached a certain intensity. This broad study enabled us to accurately determine the cholera epidemic’s mechanisms on different scales; to identify the source zones of the disease, and the groups of populations acting as vectors of the spread. diffuseur artisanal de chlore pour desinfecter les puits lors de l'epidemie de cholera de douala.: seasonality of cholera from 1974 to 2005: a review of global patterns, int. spatial distribution of cholera in the provinces of katanga and of the oriental kasa¨ı from 2002 to 2005. this new comprehensive strategy was discussed during a workshop gathering the main stakeholders held from 17 to 18 december 2007 in kinshasa and further formalized in the strategic plan for the elimination of cholera in the drc 2008–2012 approved by the minister of health of drc. using a knowledge, attitudes and practices survey to supplement findings of an outbreak investigation: cholera prevention measures during the 1991 epidemic in peru. from lakeside to main cities, the spread of cholera was favoured by fishing and fish trading activities that provoke cascades of outbreaks hitting the successive towns located on the major communication routes, including railway and ship crossings. the author further argues that even though introduction of cholera within a community is likely to be waterborne, transmission within the community is likely to occur through several routes at the same time. in this town, cholera never stopped for more than 6 years (fig.: cazelles regional-scale climate-variability synchrony of cholera epidemies in west africa, bmc infect. indeed, since its introduction in conacry in 1970, cholera has spread all over sub-saharan africa and still provokes epidemics, despite hundreds of emergency programs implemented by ngos. the study reported a 25% reduction in cholera incidence over the evaluation period, though the difference was not statistically significant. the revival of the fight against cholera originates from the above described epidemiological studies. the past, it was a common practice in cholera outbreaks to spray the houses of cholera patients with disinfectant. in africa, a similar phenomenon could possibly explain some of the outbreaks of cholera spreading from coastal areas, but it hardly explains how the disease can hit areas located thousands of kilometres away from the coast. spatial distribution of cholera in the provinces of katanga and of the oriental kasa¨ı from 2002 to 2005. thus, remote or lack of access to safe drinking water in some of the limited areas located in lakeshore cities appears to be the primary cause of cholera outbreaks. a few studies have been published, dealing with the link between climate and cholera (emch et al.: climatic, socio-economic, and health factors affecting human vulnerability to cholera in the lake victoria basin, east africa, ambio, 36(4), 350–358, 2007. veoliaforce experts will give a helping hand throughout, from the definition of the strategy to its effective implementation, in order to eradicate cholera. study found a clear lack of evidence to help guide implementers decide what approach and intervention to select during a cholera outbreak.: cazelles regional-scale climate-variability synchrony of cholera epidemies in west africa, bmc infect. veoliaforce experts will give a helping hand throughout, from the definition of the strategy to its effective implementation, in order to eradicate cholera. whilst knowledge and perceived importance of cholera prevention methods was high, this did not translate into practice. more specifically, cholera will be considered eliminated once the annual incidence rate is below 1 case out of 100 000 inhabitants; in other words, less than 500 new cases per year (nowadays, the incidence is on average 270 cases out of 100 000 inhabitants for the whole country). transmission of epidemic vibrio cholerae o1 in rural western kenya associated with drinking water from lake victoria: an environmental reservoir for cholera? the strategy presented here revives the hope to eliminate cholera in the drc. consequently, available human and financial resources are easier to gather on a few sites to hopefully tackle cholera until its complete elimination from the eastern region of the drc. the clinical care of cholera sufferers will continue to be based on rehydration at the treatment centres for diarrhoeal diseases. the environmental vibrio cholerae strains emerge and spread in human communities during monsoon seasons (koelle et al. :epidemics, democratic republic of congo, sanitation, water supply, choleratop of page.

The Health Impacts of Climate Change: A Study of Cholera in

this paper presents a systematic literature review investigating the function, use and impact of wash interventions implemented to control cholera. moreover, the ministry of public health of the drc has set the goal of total “elimination” of cholera approaching 2012. the environmental vibrio cholerae strains emerge and spread in human communities during monsoon seasons (koelle et al.: transmission of epidemic vibrio cholerae o1 in rural western kenya associated with drinking water from lake victoria: an environmental reservoir for cholera? this broad study enabled us to accurately determine the cholera epidemic’s mechanisms on different scales; to identify the source zones of the disease, and the groups of populations acting as vectors of the spread. the pursued goal was to refine the epidemiological and water supply diagnosis of the cholera recurrence.: critical factors influencing the occurrence of vibrio cholerae in the environment of bangladesh, appl.: lakes as source of cholera outbreaks, democratic republic of congo, emerg.: transmission of epidemic vibrio cholerae o1 in rural western kenya associated with drinking water from lake victoria: an environmental reservoir for cholera? spatial distribution of cholera in the provinces of katanga and of the oriental kasa¨ı from 2002 to 2005. this broad study enabled them to accurately determine the mechanisms of the cholera epidemics on different scales, to identify the source zones of the disease, and the groups of populations acting as vectors of the spread., therefore, decided to develop research work intended to facilitate the understanding of the epidemiology of cholera in eastern drc and to disseminate the acquired knowledge so as to ensure an improvement of the strategy for continuing the fight against cholera. however, the project can already be considered meaningful in it’s progress in the fight against cholera on the african continent simply because the very idea of eliminating this epidemic disease has been brought forward. plan for the elimination of cholera is now drawn up and ratified. to inform further research, policy and practice, a systematic review was conducted on the current evidence for uptake, use and health impact of wash interventions to control cholera. since this period, more than one hundred cholera outbreaks have been investigated, most of them in katanga, south and north kivu provinces, and dozens of emergency programs have been implemented. the pursued goal was to refine the epidemiological and water supply diagnosis of the cholera recurrence.: the true burden and risk of cholera: implications for prevention and control, lancet infect. the drc, the area of the provinces hit by cholera is equal to the size of france, spain and portugal together. since the cholera outbreaks in london in the 1850s, and the ground breaking work of john snow, cholera seems to be synonymous with water quality, and the associated interventions. discussion about the relative importance of each intervention seems trivial, as ideally for diseases like cholera, with multiple transmission routes, all interventions should be implemented simultaneously. in order to eliminate cholera in the drc, 7 strategic adjustments have been determined:Empowerment of the activities of epidemiological surveillance. cross-sectional studies, two in africa and two in latin america, were identified as evaluating community knowledge, and awareness of cholera prevention, and all reported a positive effect. this review found a lack of studies evaluating wash interventions implemented to control cholera. research to field action: example of the fight against cholera in the democratic republic of congo. A single study in an endemic setting compared a combination of interventions to improve water and sanitation infrastructure, and the resulting reductions in cholera incidence. this myth is now vanishing with the results showing that epidemics only originate in lakeshore regions where targeted actions on water supply are reducing cholera epidemics. who experts estimate that the true burden of cholera is as high as 5. countries hit by cholera are not so numerous, even in africa (in 2007, among the 34 african countries which have declared cases of cholera to who, only 17 had more than one thousand cases (who, 2008) and among them, the drc was one of the hardest places to implement such a study, regarding the immensity of its territory, the difficulties to collect data in remote areas and the conflict in the eastern part of the country. spatial distribution of cholera in the provinces of katanga and of the oriental kasa¨ı from 2002 to 2005. studies, conducted by the 4th direction of the congolese ministry of health and a north-south university network, clearly pointed out the role of seven cities located on the lake’s shore that act as the main source of cholera epidemics, namely bukama, bukavu, bunia, goma, kalemie, kasenga and uvira.: climatic, socio-economic, and health factors affecting human vulnerability to cholera in the lake victoria basin, east africa, ambio, 36(4), 350–358, 2007.

CHOLERA PREVENTION AND CONTROL: GUIDELINES FOR

for chlorination in particular, evidence from non-cholera emergencies indicates that effective use was highest where households with contaminated water were targeted, the treatment method effectively treated the water and the population was familiar with the method and was willing to use it [25]. the questions emerging from the cholera project will go through real-time analysis by the “direction de la lutte contre la maladie” (branch of the congolese public health ministry dedicated to fight epidemics) with the technical support of an international network of universities and the financial support from different stakeholders. using regression techniques, we statistically examined the relationship between the number of cholera cases in each health district and the following list of geographic and environmental variables: area; population; presence of cities whose population ran over 100 000 inhabitants; means of transportation such as railway stations, harbours, major tracks or roads; and lakes. likewise, the epidemiological arguments and their suitability with the national scheme for the elimination of cholera can be both a real asset in the search for funds in the sphere of sustainable development as well as for emergency answers.: the true burden and risk of cholera: implications for prevention and control, lancet infect. cholera largely perceived as a waterborne infection, other transmission routes like the consumption of contaminated food as a result of poor hand hygiene, and person-to-person transmission appear to be overlooked in the literature. the targeted zones for this activity consists of the previously mentioned regions as well as a few nearby-located great urban centres (lubumbashi, likasi, kolwezi, kamina in katanga and mbuji-mayi in oriental kasaï) where the data analysis stressed their vulnerability to cholera. evaluation of pot-chlorination of wells during a cholera outbreak, bissau, guinea-bissau, 2008. from lakeside to main cities, the spread of cholera was favoured by fishing and fish trading activities that provoke cascades of outbreaks hitting the successive towns located on the major communication routes, including railway and ship crossings. given the rapid onset and high mortality associated with cholera outbreaks, water quality interventions are perceived as being the easiest, quickest and cheapest to deploy, especially when compared to sanitation and water supply programmes which require large investments in infrastructure. indeed, the heterogeneity of cholera epidemic patterns from one area to another matches their main geographical characteristics: lacustrine areas have been more severely hit (fig. the main desire of those involved in cholera control is to limit the speed of transmission and to reduce mortality, whilst establishing baselines, and research in general, is often seen as taking valuable time and resources away from life-saving activities. impact of health education programme on knowledge, attitude and practice (kap) of people in cholera affected areas of luapula province—zambia. This broad study enabled us to accurately determine the cholera epidemic’s mechanisms on different scales; to identify the source zones of the disease, and the groups of populations acting as vectors of the spread.. to summarize, from 2002 to 2005, reports of cholera cases and deaths from cholera were collected weekly from each health district of katanga and eastern kasai provinces. on the contrary, due to these iterative outbreaks that hit katanga and kivu provinces, the drc is nowadays the country that reports the highest number of cholera cases in the world to who. studies on interventions to prevent eltor cholera transmission in urban slums., this epidemiological study also pointed out the inadequacy of the past strategy used to fight cholera in the drc, which was based upon classical reactive posture in emergency situations. results of this testing showed that the incidence of cholera infection was reduced by 75% (p<0. according to official reports, cholera was responsible for 902 071 new cases and 21 417 deaths during the last six years (who, 2003, 2004, 2005, 2006, 2007, 2008).: taylor dl, kahawita tm, cairncross s, ensink jhj (2015) the impact of water, sanitation and hygiene interventions to control cholera: a systematic review., our deepest thanks goes to: the contributors attending the 17 and 18 december 2007 in kinshasa, the workshop on the adoption of the strategic plan for the elimination of cholera in drc; to philippe barragne-bigot and to the drc unicef for the promotion of the plan for cholera elimination and their support for the publication of the “bulletin du projet d’elimination du choléra en rdc (belichol). This paper presents a systematic literature review investigating the function, use and impact of WASH interventions implemented to control cholera. we, therefore, implemented research work which intends to understand the epidemiology of cholera in the drc and to ensure improvements in the strategy to fight against cholera.. we would like to acknowledge and extend our heartfelt gratitude to the following persons and entities that have made the completion of this article possible: the public health ministry of the drc, the congolese medical teams of the provinces of katanga, south kivu, north kivu, and the oriental and maniema province, to the researchers of the university of franche-comté (patrick giraudoux, martine piarroux, bertrand sudre) still involved in the cholera research. indeed, identifying the particular foci that act as the source of cholera epidemics on the whole continent and establishing a map of high risks areas, is an indispensable prerequisite before implementing a program targeting cholera in africa. in these areas, contaminated surface water (mainly lakes) used by thousands of people for drinking or for personal hygiene is obviously the source of cholera epidemics (fig. uptake of household disinfection kits as an additional measure in response to a cholera outbreak in urban areas of haiti. assessed the effectiveness of interventions implemented during the 2010 cholera outbreak in haiti, which included mass media campaigns, community health worker activities, and distribution of water purification tablets, soap and oral rehydration solution [27]. while european research workers accompany them with their experience and methodology, they benefit from a network of very efficient and reactive collectors of epidemiological information, which enables them to produce an excellent tool in order to follow the real-time evolution of cholera and to establish modelled risk patterns. hygiene promotion, more precisely hand washing with soap, should be an integral component of any cholera control program. if the epidemiological supervision shows that cholera is receding from katanga since the first 2008 quarter, it is obvious that the fight against cholera has just begun and that extensive work on safe water supply is to be expected.

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