Cholera outbreak caused by drinking unprotected well water contaminated with faeces from an open storm water drainage: Kampala City, Uganda, January 2019

Background Kampala city slums, with one million dwellers living in poor sanitary conditions, frequently experience cholera outbreaks. On 6 January 2019, Rubaga Division notified the Uganda Ministry of Health of a suspected cholera outbreak in Sembule village. We investigated to identify the source and mode of transmission, and recommended evidence-based interventions. Methods We defined a suspected case as onset of profuse, painless, acute watery diarrhoea in a Kampala City resident (≥ 2 years) from 28 December 2018 to 11 February 2019. A confirmed case was a suspected case with Vibrio cholerae identified from the patient’s stool specimen by culture. We found cases by record review and active community case-finding. We conducted a case–control study in Sembule village, the epi-center of this outbreak, to compare exposures between confirmed case-persons and asymptomatic controls, individually matched by age group. We overlaid rainfall data with the epidemic curve to identify temporal patterns between rain and illnesses. We conducted an environmental assessment, interviewed village local council members, and tested water samples from randomly-selected households and water sources using culture and PCR to identify V. cholerae. Results We identified 50 suspected case-patients, with three deaths (case-fatality rate: 6.0%). Of 45 case-patients with stool samples tested, 22 were confirmed positive for V. cholerae O1, serotype Ogawa. All age groups were affected; persons aged 5–14 years had the highest attack rate (AR) (8.2/100,000). The epidemic curve showed several point-source outbreaks; cases repeatedly spiked immediately following rainfall. Sembule village had a token-operated water tap, which had broken down 1 month before the outbreak, forcing residents to obtain water from one of three wells (Wells A, B, C) or a public tap. Environmental assessment showed that residents emptied their feces into a drainage channel connected to Well C. Drinking water from Well C was associated with illness (ORM–H = 21, 95% CI 4.6–93). Drinking water from a public tap (ORM–H = 0.07, 95% CI 0.014–0.304) was protective. Water from a container in one of eight households sampled tested positive for V. cholerae; water from Well C had coliform counts ˃ 900/100 ml. Conclusions Drinking contaminated water from an unprotected well was associated with this cholera outbreak. We recommended emergency chlorination of drinking water, fixing the broken token tap, and closure of Well C.

Exploring relationships between drought and epidemic cholera in Africa using generalised linear models

Background Temperature and precipitation are known to affect Vibrio cholerae outbreaks. Despite this, the impact of drought on outbreaks has been largely understudied. Africa is both drought and cholera prone and more research is needed in Africa to understand cholera dynamics in relation to drought. Methods Here, we analyse a range of environmental and socioeconomic covariates and fit generalised linear models to publicly available national data, to test for associations with several indices of drought and make cholera outbreak projections to 2070 under three scenarios of global change, reflecting varying trajectories of CO2 emissions, socio-economic development, and population growth. Results The best-fit model implies that drought is a significant risk factor for African cholera outbreaks, alongside positive effects of population, temperature and poverty and a negative effect of freshwater withdrawal. The projections show that following stringent emissions pathways and expanding sustainable development may reduce cholera outbreak occurrence in Africa, although these changes were spatially heterogeneous. Conclusions Despite an effect of drought in explaining recent cholera outbreaks, future projections highlighted the potential for sustainable development gains to offset drought-related impacts on cholera risk. Future work should build on this research investigating the impacts of drought on cholera on a finer spatial scale and potential non-linear relationships, especially in high-burden countries which saw little cholera change in the scenario analysis.

Multiscale Home: Shifting Landscapes and Living-in-Movement in Haiti

In January 2010, a catastrophic earthquake ravaged Haiti. In areas such as Port-au-Prince, the tragedy was compounded by an ensuing cholera outbreak. Here, conditions of prolonged crisis illuminate people’s resilient house-ing responses at the intersection of two dynamics: the vital relational character of Haitian houses and the necessity of mobility for producing new life. Rooted in the Haitian post-plantation world, the house (kay) does not constitute a bounded space but is rather realized conceptually and materially at diverse scales: people belong to many interdependent houses and houses belong to many interrelated people, sutured across space and time and between the living and the dead. In the wake of the 2010 disaster, and now amid the COVID-19 pandemic, new challenges and opportunities have arisen for diasporic families as they craft ways to enact and secure multiscale forms of livelihood. Rezime Nan mwa janvye ane 2010, yon tranbleman tè vyolan te frape Ayiti. Nan kèlke zòn tankou Pòtoprens, kapital la, trajedi a te vin agrave akòz yon epidemi kolera. Kriz pwolonje sa a montre detèminasyon moun yo nan yon entèseksyon ki gen ladan l de dinamik: 1) youn ki montre karaktè relasyonèl ak vital kay ayisien yo; 2) lòt la ki konsantre l sou mouvman pou bay lavi a sans. Kay, ki gen rasin li nan mond apre peryòd plantasyon an, li pa sèlman yon espas ki separe ak yon fwontyè fizik, men konseptyèlman e materyèlman nan plizyè echèl: moun yo fè pati plizyè kay entèdepandan, epi tou kay yo apateni ak plizyè moun ki entèrelasyone, gras a lyen ke yo genyen ki limite nan espas ak nan tan, ant moun vivan yo ak sila ki mouri yo. Nan dezas 2010 la ak nan moman pandemi Kovid-19 la, fanmi yo gen nouvo defi ak opòtinite pandan y ap kreye nouvo mwayen nan plizyè dimansyon pou lavi ka kontinie. Resumen En enero de 2010 un violento terremoto devastó Haití. En zonas como la capital, Port-au-Prince, la tragedia se vio agravada por una epidemia de cólera. La crisis prolongada ilumina la resiliencia de las personas en la intersección de dos dinámicas: una, que señala el carácter relacional y vital de los hogares haitianos y, otra, que tematiza la movilidad para producir vida. Enraizada en el mundo de la post-plantación, la casa (kay) no es sólo un espacio delimitado por fronteras físicas, sino que se realiza conceptual y materialmente en escalas múltiples: las personas pertenecen a varias casas interdependientes y las casas pertenecen a varias personas interrelacionadas, en vínculos suturados a través del espacio y del tiempo, entre los vivos y los muertos. Entre la catástrofe de 2010 y la pandemia de Covid-19 surgen nuevos desafíos y oportunidades para las familias diaspóricas que encuentran nuevas formas de asegurar la vida en múltiples escalas. Resumo Em janeiro de 2010 um violento terremoto devastou o Haiti. Em áreas como a capital, Port-au-Prince, a tragédia foi agravada por uma epidemia de cólera. A crise prolongada ilumina a resiliência das pessoas na interseção de duas dinâmicas: a que aponta o caráter relacional e vital das casas haitianas e a que tematiza a mobilidade para produzir vida. Enraizada no mundo pós-plantação, a casa (kay) não é só um espaço limitado por fronteiras físicas, mas realizada conceitual e materialmente em diversas escalas: as pessoas pertencem a muitas casas interdependentes e as casas pertencem a muitas pessoas inter-relacionadas, através de vínculos suturados no espaço e no tempo e entre vivos e mortos. Na esteira do desastre de 2010, e em meio à pandemia de Covid-19, novos desafios e oportunidades surgem para as famílias diaspóricas à medida que criam novas maneiras de assegurar formas vitais em múltiplas escalas.

The enigma of Pacini’s Vibrio cholerae discovery

During the 1854 cholera outbreak in Florence, Italy, Filippo Pacini documented that the cause of the infection was a bacterium. This conclusion was also independently reached by John Snow during the 1854 cholera outbreak in London. By using an epidemiological method, Snow found that the infection spread through a polluted water network. Snow identified a water pump as the source of the disease. After removing the infected handle of this pump, the cases of cholera rapidly began to decrease. A microscopic examination of the water showed organic impurities but no bacteria. This discovery was ignored during Snow’s lifetime. In contrast, through microscopy during the autopsies of cholera victims, Pacini observed that the disruption of their intestinal mucosa was closely associated with millions of the bacteria that he called Vibrio cholerae . Via histological techniques, Pacini detected that intestinal mucosa reabsorption dysfunction was the cause of debilitating diarrhoea, vomiting, severe dehydration and death. Nevertheless, his discovery of Vibrio cholerae was ignored during Pacini’s lifetime. A survey of Pacini’s autographic manuscripts suggests that Pacini and Snow may have shared mutual knowledge within their respective seminal papers. This survey also facilitates, for the first time, the creation of maps that illustrate the worldwide distribution of Pacini’s cholera papers from 1854 to 1881. The consistent neglect of Pacini’s discovery remains a true enigma.

Niger's humanitarian situation looks set to worsen

Significance On Niger’s side of the border, by September 27 there were over 5,000 cases across six of the country’s eight regions -- numbers exceeding those of the country’s last major outbreak in 2018. The outbreak compounds Niger’s existing health, natural disaster, food security and displacement challenges, all in the world’s poorest country. Impacts The public health crises and other strains add to the worsening insecurity and COVID-19 burdens. Endemic malaria places the rudimentary health system under permanent strain, leaving it ill-equipped to deal with disease outbreaks. Rising levels of displacement could slow down efforts to stem the cholera outbreak.

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

Background Bangladesh 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. Methods Diarrhea 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. Results During 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%). Conclusion Vigilance for cholera patients by routine surveillance, preparedness, and response readiness for surges and oral cholera vaccination campaigns can alleviate the threats of cholera.

Coordination during Cholera Outbreak Response: Critical Insights from Yemen

Within the humanitarian arena and since the introduction of the humanitarian reform process in 2005, the cluster approach was introduced to strengthen the cooperation and accountability between agencies working in the same field. Such an integrated approach is particularly needed and relevant in emergencies like cholera, especially in countries undergoing internal conflicts like Yemen. Several areas of concern have been identified during the past field experiences, which include dysfunctional cooperation as a result of different mandates as well as the relationship between nongovernmental organizations and their donors. Control of environmental health services is, for instance, the responsibility of several clusters/agencies and stakeholders, which usually results in a complicated and sometimes confusing approaches to address gaps and barriers. As far as the drinking water quality monitoring and surveillance are concerned, sampling and testing and compilation of data are usually carried out by many agencies included in the Health and water sanitation ad hygiene (WASH) clusters. We believe that the cluster theoretical approach for emergency response remains a turning point for the humanitarian arena. However, lessons from the recent past, especially in the management of cholera outbreak in fragile settings, may serve for a serious reflection on roles and dynamics within the blurred border between health and WASH. Specifically, cluster leads in the field have the responsibility for ensuring that humanitarian actors working in their sectors remain actively engaged in addressing crosscutting concerns such as the environment.

Exploring relationships between drought and epidemic cholera in Africa using generalised linear models

Background: Temperature and precipitation are known to affect Vibrio cholerae outbreaks. Despite this, the impact of drought on outbreaks has been largely understudied. Africa is both drought and cholera prone and more research is needed in Africa to understand cholera dynamics in relation to drought. Methods: Here, we analyse a range of environmental and socioeconomic covariates and fit generalised linear models to publicly available national data, to test for associations with several indices of drought and make cholera outbreak projections to 2070 under three scenarios of global change, reflecting varying trajectories of CO₂ emissions, socio-economic development, and population growth. Results: The best-fit model implies that drought is a significant risk factor for African cholera outbreaks, alongside positive effects of population, temperature and poverty and a negative effect of freshwater withdrawal. The projections show that following stringent emissions pathways and expanding sustainable development may reduce cholera outbreak occurrence in Africa, although these changes were spatially heterogeneous. Conclusions: Despite an effect of drought in explaining recent cholera outbreaks, future projections highlighted the potential for sustainable development gains to offset drought-related impacts on cholera risk. Future work should build on this research investigating the impacts of drought on cholera on a finer spatial scale and potential non-linear relationships, especially in high-burden countries which saw little cholera change in the scenario analysis.

Memorials to John Snow – Pioneer in anaesthesia and epidemiology

John Snow was an English physician and a founding father of epidemiology, whose name is inextricably linked with tracing the source of the 1854 cholera outbreak in Soho, which killed over 600 people. Despite his recommendation to remove the water pump handle and thus reduce the spread of cholera, his theory of faecal–oral transmission was not widely believed until after his death. Furthermore, he also pioneered substantial achievements in the development of anaesthesia. He studied both chloroform and ether, improving the accuracy of their delivery. In his obstetric practice, he achieved the feat of obtaining satisfactory analgesia with a safer technique and is remembered for administering chloroform to Queen Victoria, during the delivery of her last two children. There are several interesting and unusual memorials to Snow, ranging from replica water pumps, blue plaques and a public house named after him. The most recent new memorial was erected in 2017, in his home town of York, which commemorates his origins and his subsequent contribution to curbing the cholera outbreak. All the memorials commemorate his achievements, which remain relevant today. Public health and epidemiology expertise is required in the current world of the COVID-19 pandemic, where his legacy remains as important as ever.