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Cholera outbreaks affect communities that lack access to safe water and adequate sanitation (1). Spatiotemporal clustering patterns of cholera indicate a high risk of transmission to the neighboring households of [...]

Cholera is an acute life-threatening diarrheal disease responsible for [approximately equal to]4.3 million cases and 142,000 deaths annually worldwide (1). Excluding epidemic peaks in Haiti and Yemen (2,3), most cases [...]

Background: Diarrhoea is one of the leading causes of disability-adjusted life years (DALYs) among children below five years, though the proportion of the burden occurring amongst those aged over 70 is increasing. The cost of treating and managing diarrhoea can place a burden on individuals, their households, and society in general. The cost can be high but is often undocumented, and many studies focus on children or hospitalised patients only. This study aimed to estimate the economic cost per case of diarrhoea amongst individuals of any age in Uvira, Democratic Republic of the Congo. Methods: The study was cross-sectional and retrospective, and based on a household survey approximately representative of the city undertaken in September 2021. Data on quantities and prices of resources were collected in the survey, as well as from interviews with staff at the Cholera Treatment Centre in the Uvira general hospital and their records on resource use and patient numbers. Direct and indirect costs were measured from the societal perspective, and generalised linear regression used to identify factors associated with higher costs. Results: Of 2,820 members of the 528 households surveyed, 175 people (6.2%) were reported to have had diarrhoea in the previous seven days. The majority sought care (91%) of which most (64%) visited a pharmacy. The average economic cost of illness (COI) for an episode of diarrhoea was 33,816 Congolese Francs (CDF) (US$ 17.0) in 2021 prices. The median was CDF 14,000 (US$ 7.0). The average out of pocket COI to patients was CDF 15,579 (US$ 7.8), representing 9% of the estimated average monthly income of households. On average caregivers and patients lost 4 days per episode. A concentration index suggested a lower economic COI among poorer households (p=0.099). A regression analysis identified that being older than 5 years (p=0.001) or being water insecure (p=0.032) were associated with higher COI. Conclusion: Households in Uvira experience many diarrhoeal episodes per year, and the COI is an important burden for them and society. These costs could be avoided if diarrhoea were prevented through public health interventions to reduce prevalence and care-seeking was better managed to avert this public health burden. Author summary: The cost of treating and managing diarrhoea can place a burden on individuals, their households, and society in general. The cost is often undocumented, and many studies focus on children or hospitalised patients only. We estimated the cost borne per case of diarrhoea in Uvira, Democratic Republic of the Congo, by asking people with family members experiencing diarrhoea in the past 7 days about the costs they faced. Out of 2,820 members of the 528 households we interviewed overall, 175 people (6.2%) had diarrhoea in the previous 7 days. Most (64%) visited a pharmacy to seek care. The average economic cost per episode of diarrhoea was 33,816 Congolese Francs (CDF) (US$ 17.0) in 2021 prices, including both money spent out of pocket and indirect costs (e.g. lost caregiver or patient wages). The average out of pocket cost was CDF 15,579 (US$ 7.8). These costs could be avoided if diarrhoea were prevented through public health interventions to reduce prevalence and care-seeking was better managed to avert this public health burden. [ABSTRACT FROM AUTHOR]

Background: Safely managed drinking water is critical to prevent diarrhoeal diseases, including cholera, but evidence on the effectiveness of piped water supply in reducing these diseases in low-income and complex emergency settings remains scarce. Methods: We conducted a trial of water supply infrastructure improvements in Uvira (DRC). Our primary objective was to estimate the relationship between a composite index of water service quality and the monthly number of suspected cholera cases admitted to treatment facilities and, as a secondary analysis, the number of cases confirmed by rapid diagnostic tests. Other exposures included the quantity of supplied water and service continuity. We used Poisson generalised linear models with generalised estimating equations to estimate incidence rate ratios. Findings: Associations between suspected cholera incidence and water service quality (RR 0·86, 95% CI 0·73–1·01), quantity (RR 0·80, 95% CI 0·62–1·02) and continuity (RR 0·81, 95% CI 0·77–0·86) were estimated. The magnitudes of the associations were similar between confirmed cholera incidence and water service quality (RR 0·84, 95% CI 0·73–0·97), quantity (RR 0·76, 95% CI 0·61–0·94) and continuity (RR 0·75, 95% CI 0·69–0·81). These results suggest that an additional 5 L/user/day or 1.2 hour per day of water production could reduce confirmed cholera by 24% (95% CI 6–39%) and 25% (95% CI 19–31%), respectively. Interpretation: Ensuring a sufficient and continuous piped water supply may substantially reduce the burden of endemic cholera and diarrhoeal diseases but evaluating this rigorously is challenging. Pragmatic strategies are needed for public health research on complex interventions in protracted emergency settings. Trial registration: The trial is registered in ClinicalTrials.gov ID NCT02928341. https://classic.clinicaltrials.gov/ct2/show/NCT02928341. Author summary: Diarrhoeal diseases including cholera remain a leading cause of mortality and morbidity, especially in areas with limited access to safe water, sanitation and hygiene (WASH). However, evidence for the effect of piped water supply in reducing diarrhoeal diseases and cholera in complex emergency settings remains scarce. We evaluated a large-scale infrastructure programme to improve and expand the piped drinking water supply service in the town of Uvira (South Kivu, Democratic Republic of the Congo), an area with a high burden of cholera and diarrhoeal diseases. We used five years of data from clinical surveillance and systematic cholera confirmation by rapid diagnostic tests in order to estimate associations between water supply infrastructure interventions and the incidence of diarrhoeal diseases and cholera. Our findings are consistent with existing evidence that a high-quality (or "safely managed") water service can be effective in reducing the burden of diarrhoeal diseases and cholera in low-income urban settings. Beyond overall service quality, the quantity of water supplied to the household and the continuity of the drinking water supply were both associated with a reduced risk of cholera. [ABSTRACT FROM AUTHOR]

Children under‐5 years of age are particularly vulnerable to severe acute malnutrition (SAM), and the risk factors associated with relapse to SAM are poorly understood. Possible causes are asymptomatic or symptomatic infection with enteric pathogens, with contaminated food as a critical transmission route. This cross‐sectional study comprised a household survey with samples of child food (n = 382) and structured observations of food preparation (n = 197) among children aged 6–59 months that were discharged from treatment in community management of acute malnutrition (CMAM) programmes in South Sudan. We quantified Escherichia coli and total coliforms (TCs), measured in colony forming units per g of food (CFU/g), as indicators of microbial contamination of child food. A modified hazard analysis critical control point (HACCP) approach was utilised to determine critical control points (CCPs) followed by multivariate logistic regression analysis to understand the risk factors associated with contamination. Over 40% (n = 164) of samples were contaminated with E. coli (43% >0 E. coli CFU/g, 95% CI 38%–48%), and 90% (n = 343) had >10 TCs (CFU/g) (>10 TC CFU/g, 95% CI 87%–93%). Risk factors associated (p < 0.05) with child food contamination included if the child fed themselves (9.05 RR, 95% CI [3.18, 31.16]) and exposure to animals (2.63 RR, 95% CI [1.33, 5.34]). This study highlights the risk factors and potential control strategies that can support interventions that reduce food contamination exposure in young children and help further protect those that are highly vulnerable to recurrent exposure to enteric pathogens. Key messages: Food is a potentially important pathway for enteric disease transmission and a major concern for children recovered from severe acute malnutrition (SAM) in humanitarian settings.In low‐income South Sudan, 43% (n = 164) of child food samples from households with a child at risk of relapse to SAM were contaminated with Escherichia coli and 90% (n = 343) with total coliforms (TCs).Child self‐feeding and animal presence in the household were identified as key risk factors for food contamination.Future research should assess the relative importance of the identified critical control points (CCPs), including reducing animal contact in the household, improving knowledge and practices around cooking processes and hygiene practices specific to the child such as handwashing and the use of cutlery. [ABSTRACT FROM AUTHOR]

Introduction: Cholera remains a frequent cause of outbreaks globally, particularly in areas with inadequate water, sanitation and hygiene (WASH) services. Cholera is spread through faecal-oral routes, and studies demonstrate that ingestion of Vibrio cholerae occurs from consuming contaminated food and water, contact with cholera cases and transmission from contaminated environmental point sources. WASH guidelines recommending interventions for the prevention and control of cholera are numerous and vary considerably in their recommendations. To date, there has been no review of practice guidelines used in cholera prevention and control programmes. Methods: We systematically searched international agency websites to identify WASH intervention guidelines used in cholera programmes in endemic and epidemic settings. Recommendations listed in the guidelines were extracted, categorised and analysed. Analysis was based on consistency, concordance and recommendations were classified on the basis of whether the interventions targeted within-household or community-level transmission. Results: Eight international guidelines were included in this review: three by non-governmental organisations (NGOs), one from a non-profit organisation (NPO), three from multilateral organisations and one from a research institution. There were 95 distinct recommendations identified, and concordance among guidelines was poor to fair. All categories of WASH interventions were featured in the guidelines. The majority of recommendations targeted community-level transmission (45%), 35% targeted within-household transmission and 20% both. Conclusions: Recent evidence suggests that interventions for effective cholera control and response to epidemics should focus on case-centred approaches and within-household transmission. Guidelines did consistently propose interventions targeting transmission within households. However, the majority of recommendations listed in guidelines targeted community-level transmission and tended to be more focused on preventing contamination of the environment by cases or recurrent outbreaks, and the level of service required to interrupt community-level transmission was often not specified. The guidelines in current use were varied and interpretation may be difficult when conflicting recommendations are provided. Future editions of guidelines should reflect on the inclusion of evidence-based approaches, cholera transmission models and resource-efficient strategies. [ABSTRACT FROM AUTHOR]

In the 2014 West African Ebola outbreak, international organizations provided conflicting recommendations for disinfecting surfaces contaminated by uncontrolled patient spills. We compared the efficacy of four chlorine solutions (sodium hypochlorite, sodium dichloroisocyanurate, high-test hypochlorite, and generated hypochlorite) for disinfection of three surface types (stainless steel, heavy-duty tarp, and nitrile) with and without pre-cleaning practices (prewiping, covering, or both) and soil load. The test organisms were Escherichia coli and the Ebola surrogate Phi6. All tests achieved a minimum of 5.9 and 3.1 log removal in E. coli and Phi6, respectively. A 15 min exposure to 0.5% chlorine was sufficient to ensure <8 Phi6 plaque-forming unit (PFU)/cm² in all tests. While chlorine types were equally efficacious with and without soil load, variation was seen by surface type. Wiping did not increase disinfection efficacy and is not recommended because it generates infectious waste. Covering spills decreased disinfection efficacy against E. coli on heavy-duty tarp but does prevent splashing, which is critical in Ebola contexts. Our results support the recommendation of a 15 min exposure to 0.5% chlorine, independently of chlorine type, surface, pre-cleaning practices, and organic matter, as an efficacious measure to interrupt disease transmission from uncontrolled spills in Ebola outbreaks. [ABSTRACT FROM AUTHOR]