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We studied the epidemiology of cholera in Katanga and Eastern Kasai, in the Democratic Republic of Congo, by compiling a database including all cases recorded from 2000 through 2005. Results show that lakes were the sources of outbreaks and demonstrate the inadequacy of the strategy used to combat cholera. [ABSTRACT FROM AUTHOR]

Cholera is a bacterial water-borne diarrheal disease transmitted via the fecal-oral route that causes high morbidity in sub-Saharan Africa and Asia. It is preventable with vaccination, and Water, Sanitation, and Hygiene (WASH) improvements. However, the impact of vaccination in endemic settings remains unclear. Cholera is endemic in the city of Kalemie, on the shore of Lake Tanganyika, in the Democratic Republic of Congo, where both seasonal mobility and the lake, a potential environmental reservoir, may promote transmission. Kalemie received a vaccination campaign and WASH improvements in 2013-2016. We assessed the impact of this intervention to inform future control strategies in endemic settings. We fit compartmental models considering seasonal mobility and environmentally-based transmission. We estimated the number of cases the intervention avoided, and the relative contributions of the elements promoting local cholera transmission. We estimated the intervention avoided 5,259 cases (95% credible interval: 1,576.6-11,337.8) over 118 weeks. Transmission did not rely on seasonal mobility and was primarily environmentally-driven. Removing environmental exposure or contamination could control local transmission. Repeated environmental exposure could maintain high population immunity and decrease the impact of vaccination in similar endemic areas. Addressing environmental exposure and contamination should be the primary target of interventions in such settings.

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., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gallandat et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The WHO Emergency Medical Teams (EMT) Initiative coordinates the deployment of qualified medical teams who promptly respond to public health emergencies (PHEs) and provide quality service during emergencies whilst strengthening capacity. Globally, 40 EMTs have been classified between 2016 and the present (as of the writing of this article in December 2023) and are from across all the WHO regions except the WHO Africa Region (AFRO). However, WHO Africa has prioritised the implementation of EMTs in 10 priority countries to address the public health emergencies (PHEs) affecting the region., Objective: This article describes the development and progress of national EMTs in the WHO African Region over the past 7 years and elucidates the main lessons learned and the complexity and challenges in the process., Methods: This study employed a case study approach because of its appropriateness in examining a complex social phenomenon in a socio-political context in depth, using multiple lenses simultaneously. Data and information were obtained through document reviews and key informant interviews (KIIs) ( n = 5) with the members of the EMT Initiative on shared field experiences. Data were systematically analysed using the Stages of Implementation Completion (SIC) framework, and the lessons learnt were presented using components of a framework from Adini et al., Results: The Initiative commenced in the WHO African Region following its launch in December 2017 in Senegal. The assessments of the concept's engagement (involved learning and deciding), feasibility (reviewing expectation and capacity), and readiness planning (collaborating and preparing) showed that the context-specific (African context) challenges, lessons from different emergency response actions mainly guided the Initiative's pre-implementation phase in the region and prompted the WHO emergency leadership on the urgency and need for the EMT concept in the region. The assessment of the implementation processes showed progress in key areas, with staff demonstrating improved competency, EMT services maintaining high fidelity, effective consultation launching critical components, and ongoing services providing successful support and monitoring. Creating the N-EMTs and revitalising the EMT concept required an aligned strategy with other regional emergency programmes and a futuristic vision. Proposed sustainability and governance components include creating N-EMT, developing a coordination structure, collaborating with partners, and finalising the N-EMT., Conclusion: The Initiative is an imperative component that would allow better-targeted management of health emergencies in the region. The continuous refinement of the EMT initiative is crucial. There is a need to work on additional components, such as a context-specific framework for collaborations and partnerships that would enhance deployment and procurement modalities and the complementarity between other regional initiatives to improve the work. Emphasis should be placed on strengthening local health systems, enhancing training and capacity-building programmes, and fostering regional and international collaborations. Additionally, sustainable funding and resource allocation are essential to ensure the resilience of EMTs in the African region and their long-term success., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Balde, Oyugi, Mbasha, Kamara, Martinez-Monterrey, Relan, Lajolo, Bompangue, Fortin, Okeibunor, Salio, Braka, Chamla, Gueye, Yao and Fall.)

Background: Since the early 1970s, cholera outbreaks have been a major public health burden in the Democratic Republic of Congo (DRC). Cholera cases have been reported in a quasi-continuous manner in certain lakeside areas in the Great Lakes Region. As these cholera-endemic health zones constitute a starting point for outbreaks and diffusion towards other at-risk areas, they play a major role in cholera dynamics in the country. Monitoring the spatiotemporal dynamics of cholera hotspots and adjusting interventions accordingly thus reduces the disease burden in an efficient and cost-effective manner., Methods: A literature review was conducted to describe the spatiotemporal dynamics of cholera in the DRC at the province level from 1973 to 1999. We then identified and classified cholera hotspots at the provincial and health zone levels from 2003 to 2022 and described the spatiotemporal evolution of hotspots. We also applied and compared three different classification methods to ensure that cholera hotspots are identified and classified according to the DRC context., Results: According to all three methods, high-priority hotspots were concentrated in the eastern Great Lakes Region. Overall, hotspots largely remained unchanged over the course of the study period, although slight improvements were observed in some eastern hotspots, while other non-endemic areas in the west experienced an increase in cholera outbreaks. The Global Task Force on Cholera Control (GTFCC) and the Department of Ecology and Infectious Disease Control (DEIDC) methods largely yielded similar results for the high-risk hotspots. However, the medium-priority hotspots identified by the GTFCC method were further sub-classified by the DEIDC method, thereby providing a more detailed ranking for priority targeting., Conclusions: Overall, the findings of this comprehensive study shed light on the dynamics of cholera hotspots in the DRC from 1973 to 2022. These results may serve as an evidence-based foundation for public health officials and policymakers to improve the implementation of the Multisectoral Cholera Elimination Plan, guiding targeted interventions and resource allocation to mitigate the impact of cholera in vulnerable communities., (© 2024. The Author(s).)

Vibrio cholerae has caused seven cholera pandemics in the past two centuries. The seventh and ongoing pandemic has been particularly severe on the African continent. Here, we report long read-based genome sequences of six V. cholerae strains isolated in the Democratic Republic of the Congo between 2009 and 2012., Competing Interests: The authors declare no conflict of interest.

A resurgence in cholera cases has been observed throughout Africa during the first half of 2023. Among the many factors that drive cholera transmission, the ongoing climate phenomenon El Niño is likely to continue until March to May 2024. To prevent further cholera spread, it is critical to strengthen cholera control efforts in Africa., Competing Interests: The authors declare no competing interests., (Copyright: Nadège Taty et al.)

Objective: This study describes the progress that the World Health Organization (WHO) African (AFRO) region has made in establishing National Emergency Medical Teams (N-EMTs), the coordination mechanisms of the EMTs, and the regional training centers., Methods: It used a retrospective descriptive analysis of the formulation and implementation of the EMTs Initiative from an insider perspective. The analysis is based on the review of available documents such as EMTs mission reports, assessments, surveys, EMT monthly bulletins, and meeting minutes in addition to key informant interviews ( n = 5) with the EMT teams' members to validate the findings and share field experiences., Results: The emergence of coronavirus disease 2019 (COVID-19) acted as an accelerator for the implementation of the EMT initiative in the AFRO region. A total of 18 EMT deployments were carried out in 16 countries in the AFRO region through the WHO EMT-network during COVID-19, providing support to countries in managing severe and critical COVID-19 cases., Conclusions: A Regional Training Center for N-EMTs is being set up in Addis Ababa to train the N-EMTs and strengthen local capacity of health personnel in the region. Challenges include unavailability of mentors to support countries in implementing N-EMTs and the Regional Simulation Training Center, poor funding, and coordination in the rolling out of the N-EMTs.

Background: The dynamics of the spread of cholera epidemics in the Democratic Republic of the Congo (DRC), from east to west and within western DRC, have been extensively studied. However, the drivers of these spread processes remain unclear. We therefore sought to better understand the factors associated with these spread dynamics and their potential underlying mechanisms., Methods: In this eco-epidemiological study, we focused on the spread processes of cholera epidemics originating from the shores of Lake Kivu, involving the areas bordering Lake Kivu, the areas surrounding the lake areas, and the areas out of endemic eastern DRC (eastern and western non-endemic provinces). Over the period 2000-2018, we collected data on suspected cholera cases, and a set of several variables including types of conflicts, the number of internally displaced persons (IDPs), population density, transportation network density, and accessibility indicators. Using multivariate ordinal logistic regression models, we identified factors associated with the spread of cholera outside the endemic eastern DRC. We performed multivariate Vector Auto Regressive models to analyze potential underlying mechanisms involving the factors associated with these spread dynamics. Finally, we classified the affected health zones using hierarchical ascendant classification based on principal component analysis (PCA)., Findings: The increase in the number of suspected cholera cases, the exacerbation of conflict events, and the number of IDPs in eastern endemic areas were associated with an increased risk of cholera spreading outside the endemic eastern provinces. We found that the increase in suspected cholera cases was influenced by the increase in battles at lag of 4 weeks, which were influenced by the violence against civilians with a 1-week lag. The violent conflict events influenced the increase in the number of IDPs 4 to 6 weeks later. Other influences and uni- or bidirectional causal links were observed between violent and non-violent conflicts, and between conflicts and IDPs. Hierarchical clustering on PCA identified three categories of affected health zones: densely populated urban areas with few but large and longer epidemics; moderately and accessible areas with more but small epidemics; less populated and less accessible areas with more and larger epidemics., Conclusion: Our findings argue for monitoring conflict dynamics to predict the risk of geographic expansion of cholera in the DRC. They also suggest areas where interventions should be appropriately focused to build their resilience to the disease., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2023 Kayembe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The Democratic Republic of the Congo (DRC) implemented the first strategic Multisectoral Cholera Elimination Plan (MCEP) in 2008-2012. Two subsequent MCEPs have since been implemented covering the periods 2013-2017 and 2018-2021. The current study aimed to assess the spatiotemporal dynamics of cholera over the recent 22-year period to determine the impact of the MCEPs on cholera epidemics, establish lessons learned and provide an evidence-based foundation to improve the implementation of the next MCEP (2023-2027)., Methods: In this cross-sectional study, secondary weekly epidemiological cholera data covering the 2000-2021 period was extracted from the DRC Ministry of Health surveillance databases. The data series was divided into four periods: pre-MCEP 2003-2007 (pre-MCEP), first MCEP (MCEP-1), second MCEP (MCEP-2) and third MCEP (MCEP-3). For each period, we assessed the overall cholera profiles and seasonal patterns. We analyzed the spatial dynamics and identified cholera risk clusters at the province level. We also assessed the evolution of cholera sanctuary zones identified during each period., Results: During the 2000-2021 period, the DRC recorded 520,024 suspected cases and 12,561 deaths. The endemic provinces remain the most affected with more than 75% of cases, five of the six endemic provinces were identified as risk clusters during each MCEP period (North Kivu, South Kivu, Tanganyika, Haut-Lomami and Haut-Katanga). Several health zones were identified as cholera sanctuary zones during the study period: 14 health zones during MCEP-1, 14 health zones during MCEP-2 and 29 health zones during MCEP-3. Over the course of the study period, seasonal cholera patterns remained constant, with one peak during the dry season and one peak during the rainy season., Conclusion: Despite the implementation of three MCEPs, the cholera context in the DRC remains largely unchanged since the pre-MCEP period. To better orient cholera elimination activities, the method used to classify priority health zones should be optimized by analyzing epidemiological; water, sanitation and hygiene; socio-economic; environmental and health indicators at the local level. Improvements should also be made regarding the implementation of the MCEP, reporting of funded activities and surveillance of cholera cases. Additional studies should aim to identify specific bottlenecks and gaps in the coordination and strategic efforts of cholera elimination interventions at the local, national and international levels., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Monkeypox (MPX) is an emergent severe zoonotic disease resembling that of smallpox. To date, most cases of human MPX have been reported in the Democratic Republic of the Congo (DRC). While the number of cases has increased steadily in the DRC over the last 30 years, the environmental risk factors that drive the spatiotemporal dynamics of MPX transmission remain poorly understood. This study aimed to investigate the spatiotemporal associations between environmental risk factors and annual MPX incidence in the DRC. All MPX cases reported weekly at the health zone level over a 16-year period (2000-2015) were analyzed. A Bayesian hierarchical generalized linear mixed model was conducted to identify the spatiotemporal associations between annual MPX incidence and three types of environmental risk factors illustrating environment as a system resulting from physical, social and cultural interactions Primary forest (IRR 1.034 [1.029-1.040]), economic well-being (IRR 1.038 [1.031-1.047]), and temperature (IRR 1.143 [1.028-1.261]) were positively associated with annual MPX incidence. Our study shows that physical environmental risk factors alone cannot explain the emergence of MPX outbreaks in the DRC. Economic level and cultural practices participate from environment as a whole and thus, must be considered to understand exposure to MPX risk Future studies should examine the impact of these factors in greater detail., (© 2022. EcoHealth Alliance.)

The paper documents experiences and lesson learned in responding to COVID-19 pandemic in Eswatini with the support of the Emergency Medical Teams. WHO databases, operation reports and hospitalization records were reviewed. The WHO Emergency Medical Teams built the capacity of the local response teams in Eswatini. The conclusion is that following the intervention of the WHO Emergency Medical Teams, Eswatini is better prepared to respond to the ongoing COVID-19 pandemic and future outbreaks., Competing Interests: The authors declare no competing interests., (Copyright: Ngoy Nsenga et al.)

Cholera is endemic along the Great Lakes Region, in eastern Democratic Republic of the Congo (DRC). From these endemic areas, also under perpetual conflicts, outbreaks spread to other areas. However, the main routes of propagation remain unclear. This research aimed to explore the modalities and likely main routes of geographic spread of cholera from endemic areas in eastern DRC. We used historical reconstruction of major outbreak expansions of cholera since its introduction in eastern DRC, maps of distribution and spatiotemporal cluster detection analyses of cholera data from passive surveillance (2000-2017) to describe the spread dynamics of cholera from eastern DRC. Four modalities of geographic spread and their likely main routes from the source areas of epidemics to other areas were identified: in endemic eastern provinces, and in non-endemic provinces of eastern, central and western DRC. Using non-parametric statistics, we found that the higher the number of conflict events reported in eastern DRC, the greater the geographic spread of cholera across the country. The present study revealed that the dynamics of the spread of cholera follow a fairly well-defined spatial logic and can therefore be predicted., Competing Interests: The authors have declared that no competing interests exist.

Background: Overall, 1.8 million children fail to receive the 3-dose series for diphtheria, tetanus and pertussis each year in the Democratic Republic of the Congo (DRC). Currently, an emergency plan targeting 9 provinces including Kinshasa, the capital of the DRC, is launched to reinforce routine immunization. Mont Ngafula II was the only health district that experienced high vaccination dropout rates for nearly five consecutive years. This study aimed to identify factors predicting high immunization dropout rates among children aged 12-23 months in the Mont Ngafula II health district., Methods: A cross-sectional household survey was conducted among 418 children in June-July 2019 using a two-stage sampling design. Socio-demographic and perception data were collected through a structured interviewer-administered questionnaire. The distribution of 2017-2018 immunization coverage and dropout rate was extracted from the local health district authority and mapped. Logistic random effects regression models were used to identify predictors of high vaccination dropout rates., Results: Of the 14 health areas in the Mont Ngafula II health district, four reported high vaccine coverage, only one recorded low vaccine coverage, and three reported both low vaccine coverage and high dropout rate. In the final multivariate logistic random effects regression model, the predictors of immunization dropout among children aged 12-23 months were: living in rural areas, unavailability of seats, non-compliance with the order of arrival during vaccination in health facilities, and lack of a reminder system on days before the scheduled vaccination., Conclusions: Our results advocate for prioritizing targeted interventions and programs to strengthen interpersonal communication between immunization service providers and users during vaccination in health facilities and to implement an SMS reminder system on days before the scheduled vaccination., (© 2022. The Author(s).)

Background: Cholera outbreaks in western Democratic Republic of the Congo (DRC) are thought to be primarily the result of westward spread of cases from the Great Lakes Region. However, other patterns of spatial spread in this part of the country should not be excluded. The aim of this study was to explore alternative routes of spatial spread in western DRC., Methods: A literature review was conducted to reconstruct major outbreak expansions of cholera in western DRC since its introduction in 1973. We also collected data on cholera cases reported at the health zone (HZ) scale by the national surveillance system during 2000-2018. Based on data from routine disease surveillance, we identified two subperiods (week 45, 2012-week 42, 2013 and week 40, 2017-week 52, 2018) for which the retrospective space-time permutation scan statistic was implemented to detect spatiotemporal clusters of cholera cases and then to infer the spread patterns in western DRC other than that described in the literature., Results: Beyond westward and cross-border spread in the West Congo Basin from the Great Lakes Region, other dynamics of cholera epidemic propagation were observed from neighboring countries, such as Angola, to non-endemic provinces of southwestern DRC. Space-time clustering analyses sequentially detected clusters of cholera cases from southwestern DRC to the northern provinces, demonstrating a downstream-to-upstream spread along the Congo River., Conclusions: The spread of cholera in western DRC is not one-sided. There are other patterns of spatial spread, including a propagation from downstream to upstream areas along the Congo River, to be considered as preferential trajectories of cholera in western DRC., (© 2021. The Author(s).)

Background: Bacterial meningitis occurs worldwide but Africa remains the most affected continent, especially in the "Meningitis belt" that extends from Senegal to Ethiopia. Three main bacteria are responsible for causing bacterial meningitis, i.e., N. meningitidis (Nm), S. pneumoniae and H. influenzae type b. Among Nm, serogroup A used to be responsible for up to 80 to 85% of meningococcal meningitis cases in Africa. Since 2000, other Nm serogroups including W, X and C have also been responsible for causing epidemics. This overview aims to describe the main patterns of meningitis disease cases and pathogens from 1928 to 2018 in Africa with a special focus on disease conditions "out-of-the-belt" area that is still usually unexplored. Based on basic spatio-temporal methods, and a 90-years database of reported suspected meningitis cases and death from the World Health Organization, we used both geographic information system and spatio-temporal statistics to identify the major localizations of meningitis epidemics over this period in Africa., Results: Bacterial meningitis extends today outside its historical limits of the meningitis belt. Since the introduction of MenAfrivac vaccine in 2010, there has been a dramatic decrease in NmA cases while other pathogen species and Nm variants including NmW, NmC and Streptococcus pneumoniae have become more prevalent reflecting a greater diversity of bacterial strains causing meningitis epidemics in Africa today., Conclusion: Bacterial meningitis remains a major public health problem in Africa today. Formerly concentrated in the region of the meningitis belt with Sub-Saharan and Sudanian environmental conditions, the disease extends now outside these historical limits to reach more forested regions in the central parts of the continent. With global environmental changes and massive vaccination targeting a unique serogroup, an epidemiological transition of bacterial meningitis is ongoing, requiring both a better consideration of the etiological nature of the responsible agents and of their proximal and distal determinants., (© 2021. The Author(s).)

Introduction: Bacterial meningitis still constitutes an important threat in Africa. In the meningitis belt, a clear seasonal pattern in the incidence of meningococcal disease during the dry season has been previously correlated with several environmental parameters like dust and sand particles as well as the Harmattan winds. In parallel, the evidence of seasonality in meningitis dynamics and its environmental variables remain poorly studied outside the meningitis belt. This study explores several environmental factors associated with meningitis cases in the Democratic Republic of Congo (DRC), central Africa, outside the meningitis belt area., Methods: Non-parametric Kruskal-Wallis' tests were used to establish the difference between the different health zones, climate and vegetation types in relation to both the number of cases and attack rates for the period 2000-2018. The relationships between the number of meningitis cases for the different health zones and environmental and socio-economical parameters collected were modeled using different generalized linear (GLMs) and generalized linear mixed models (GLMMs), and different error structure in the different models, i.e., Poisson, binomial negative, zero-inflated binomial negative and more elaborated multi-hierarchical zero-inflated binomial negative models, with randomization of certain parameters or factors (health zones, vegetation and climate types). Comparing the different statistical models, the model with the smallest Akaike's information criterion (AIC) were selected as the best ones. 515 different health zones from 26 distinct provinces were considered for the construction of the different GLM and GLMM models., Results: Non-parametric bivariate statistics showed that there were more meningitis cases in urban health zones than in rural conditions (χ2 = 6.910, p-value = 0.009), in areas dominated by savannah landscape than in areas with dense forest or forest in mountainous areas (χ2 = 15.185, p-value = 0.001), and with no significant difference between climate types (χ2 = 1.211, p-value = 0,449). Additionally, no significant difference was observed for attack rate between the two types of heath zones (χ2 = 0.982, p-value = 0.322). Conversely, strong differences in attack rate values were obtained for vegetation types (χ2 = 13.627, p-value = 0,001) and climate types (χ2 = 13.627, p-value = 0,001). This work demonstrates that, all other parameters kept constant, an urban health zone located at high latitude and longitude eastwards, located at low-altitude like in valley ecosystems predominantly covered by savannah biome, with a humid tropical climate are at higher risk for the development of meningitis. In addition, the regions with mean range temperature and a population with a low index of economic well-being (IEW) constitute the perfect conditions for the development of meningitis in DRC., Conclusion: In a context of global environmental change, particularly climate change, our findings tend to show that an interplay of different environmental and socio-economic drivers are important to consider in the epidemiology of bacterial meningitis epidemics in DRC. This information is important to help improving meningitis control strategies in a large country located outside of the so-called meningitis belt., Competing Interests: The authors have declared that no competing interests exist.

We hypothesized that Cholera (Vibrio cholerae) that appeared along Lake Kivu in the African Rift in the seventies, might be controlled by volcano-tectonic activity, which, by increasing surface water and groundwater salinity and temperature, may partly rule the water characteristics of Lake Kivu and promote V. cholerae proliferation. Volcanic activity (assessed weekly by the SO2 flux of Nyiragongo volcano plume over the 2007-2012 period) is highly positively correlated with the water conductivity, salinity and temperature of the Kivu lake. Over the 2007-2012 period, these three parameters were highly positively correlated with the temporal dynamics of cholera cases in the Katana health zone that border the lake. Meteorological variables (air temperature and rainfall), and the other water characteristics (namely pH and dissolved oxygen concentration in lake water) were unrelated to cholera dynamics over the same period. Over the 2016-2018 period, we sampled weekly lake water salinity and conductivity, and twice a month vibrio occurrence in lake water and fish. The abundance of V. cholerae in the lake was positively correlated with lake salinity, temperature, and the number of cholera cases in the population of the Katana health zone. V. cholerae abundance in fishes was positively correlated with V. cholerae abundance in lake water, suggesting that their consumption directly contaminate humans. The activity of the volcano, by controlling the physico-chemical characteristics of Lake Kivu, is therefore a major determinant of the presence of the bacillus in the lake. SO2 fluxes in the volcano plume can be used as a tool to predict epidemic risks., Competing Interests: The authors have declared that no competing interests exist.

Background: Bacterial meningitis remains a major threat for the population of the meningitis belt. Between 2004 and 2009, in the countries of this belt, more than 200,000 people were infected with a 10% mortality rate. However, for almost 20 years, important meningitis epidemics are also reported outside this belt. Research is still very poorly developed in this part of the word like in the Democratic Republic of Congo (DRC), which experiences recurrent epidemics. This article describes for the first time the spatio-temporal patterns of meningitis cases and epidemics in DRC, in order to provide new insights for surveillance and control measures., Methods: Based on weekly suspected cases of meningitis (2000-2012), we used time-series analyses to explore the spatio-temporal dynamics of the disease. We also used both geographic information systems and geostatistics to identify spatial clusters of cases. Both using conventional statistics and the Cleveland's algorithm for decomposition into general trend, seasonal and residuals, we searched for the existence of seasonality., Results: We observed a low rate of biological confirmation of cases (11%) using soluble antigens search, culture and PCR. The main strains found are Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis (A and C) serogroups. We identified 8 distinct spatial clusters, located in the northeastern and southeastern part of DRC, and in the capital city province, Kinshasa. A low seasonal trend was observed with higher incidence and attack rate of meningitis during the dry season, with a high heterogeneity in seasonal patterns occurring across the different districts and regions of DRC., Conclusion: Despite challenges related to completeness of data reporting, meningitis dynamics shows weak seasonality in DRC. This tends to suggest that climatic, environmental factors might be less preponderant in shaping seasonal patterns in central Africa. The characterization of 8 distinct clusters of meningitis could be used for a better sentinel meningitis surveillance and optimization of vaccine strategy in DRC. Improving biological monitoring of suspected cases should be a priority for future eco-epidemiological studies to better understand the emergence and spread of meningitis pathogens, and the potential ecological, environmental drivers of this disease.

Background: Rapid control of cholera outbreaks is a significant challenge in overpopulated urban areas. During late-2017, Kinshasa, the capital of the Democratic Republic of the Congo, experienced a cholera outbreak that showed potential to spread throughout the city. A novel targeted water and hygiene response strategy was implemented to quickly stem the outbreak., Methods: We describe the first implementation of the cluster grid response strategy carried out in the community during the cholera outbreak in Kinshasa, in which response activities targeted cholera case clusters using a grid approach. Interventions focused on emergency water supply, household water treatment and safe storage, home disinfection and hygiene promotion. We also performed a preliminary community trial study to assess the temporal pattern of the outbreak before and after response interventions were implemented. Cholera surveillance databases from the Ministry of Health were analyzed to assess the spatiotemporal dynamics of the outbreak using epidemic curves and maps., Results: From January 2017 to November 2018, a total of 1712 suspected cholera cases were reported in Kinshasa. During this period, the most affected health zones included Binza Météo, Limeté, Kokolo, Kintambo and Kingabwa. Following implementation of the response strategy, the weekly cholera case numbers in Binza Météo, Kintambo and Limeté decreased by an average of 57% after 2 weeks and 86% after 4 weeks. The total weekly case numbers throughout Kinshasa Province dropped by 71% 4 weeks after the peak of the outbreak., Conclusion: During the 2017-2018 period, Kinshasa experienced a sharp increase in cholera case numbers. To contain the outbreak, water supply and hygiene response interventions targeted case households, nearby neighbors and public areas in case clusters using a grid approach. Following implementation of the response, the outbreak in Kinshasa was quickly brought under control. A similar approach may be adapted to quickly interrupt cholera transmission in other urban settings.

Monkeypox is a viral disease with a clinical presentation resembling that of smallpox. Although monkeypox is considered to be an important zoonotic viral disease, its epidemiology remains poorly understood, especially the spatial and temporal distribution of the disease. The present study examined weekly reports of monkeypox cases collected from 2000 to 2015 at the health zone scale in the Democratic Republic of Congo. SaTScan ® was performed to identify spatial and temporal clusters of monkeypox cases. Significant primary spatial clusters were detected in the districts of Sankuru and Tshuapa. A centrifugal pattern was found, with significant primary spatial clusters extending over time from Sankuru and Tshuapa to several neighboring districts. Peaks of cases occurred from July to September for the 2000-2002 and 2003-2009 sub-periods and from January to March for the 2010-2015 sub-period. Despite the lack of additional data for confirmation, the increasing of monkeypox reported incidence was observed in the Democratic Republic of Congo during 2000-2015 period and this increase cannot be explain only by the improvements of surveillance systems. The detected spatial clusters were located in the dense rainforest of the Congo basin. The reasons for the excess incidence of monkeypox cases in the central region of the country are unknown, and the relative influence of ecological, environmental, and human factors on the mechanism of emergence of monkeypox has yet to be identified.

Background: The Integrated Disease Surveillance and Response (IDSR) strategy implemented by the World Health Organization (WHO) in Africa has produced a large amount of data on participating countries, and in particular on the Democratic Republic of Congo (DRC). These data are increasingly considered as unevaluable and, therefore, as requiring a rigorous process of validation before they can be used for research or public health purposes. The aim of this study was to propose a method to assess the level of adequacy of IDSR morbidity data in reflecting actual morbidity., Methods: A systematic search of English- and French-language articles was performed in Scopus, Medline, Science Direct, Springer Link, Cochrane, Cairn, Persée, and Erudit databases. Other types of documents were identified through manual searches. Selected articles focused on the determinants of the discrepancies (differences) between reported morbidity and actual morbidity. An adequacy score was constructed using some of the identified determinants. This score was applied to the 15 weekly reported diseases monitored by IDSR surveillance in the DRC. A classification was established using the Jenks method and a sensitivity analysis was performed. Twenty-three classes of determinants were identified in 35 IDSR technical guides and reports of outbreak investigations and in 71 out of 2254 researched articles. For each of the 15 weekly reported diseases, the SIA was composed of 12 items grouped in 6 dimensions., Results: The SIA classified the 15 weekly reported diseases into 3 categories or types: high score or good adequacy (value > = 14), moderate score or fair adequacy (value > = 8 and < 14), and low score or low or non-adequacy (value < 8). Regardless of the criteria used in the sensitivity analysis, there was no notable variation in SIA values or categories for any of the 15 weekly reported diseases., Conclusion: In a context of sparse health information in low- and middle-income countries, this study developed a score to help classify IDSR morbidity data as usable, usable after adjustment, or unusable. This score can serve to prioritize, optimize, and interpret data analyses for epidemiological research or public health purposes.

In 2017, the exacerbation of an ongoing countrywide cholera outbreak in the Democratic Republic of the Congo resulted in >53,000 reported cases and 1,145 deaths. To guide control measures, we analyzed the characteristics of cholera epidemiology in DRC on the basis of surveillance and cholera treatment center data for 2008-2017. The 2017 nationwide outbreak resulted from 3 distinct mechanisms: considerable increases in the number of cases in cholera-endemic areas, so-called hot spots, around the Great Lakes in eastern DRC; recurrent outbreaks progressing downstream along the Congo River; and spread along Congo River branches to areas that had been cholera-free for more than a decade. Case-fatality rates were higher in nonendemic areas and in the early phases of the outbreaks, possibly reflecting low levels of immunity and less appropriate prevention and treatment. Targeted use of oral cholera vaccine, soon after initial cases are diagnosed, could contribute to lower case-fatality rates.

Background: Cholera remains a persistent health problem in sub-Saharan Africa and worldwide. Cholera can be controlled through appropriate water and sanitation, or by oral cholera vaccination, which provides transient (∼3 years) protection, although vaccine supplies remain scarce. We aimed to map cholera burden in sub-Saharan Africa and assess how geographical targeting could lead to more efficient interventions., Methods: We combined information on cholera incidence in sub-Saharan Africa (excluding Djibouti and Eritrea) from 2010 to 2016 from datasets from WHO, Médecins Sans Frontières, ProMED, ReliefWeb, ministries of health, and the scientific literature. We divided the study region into 20 km × 20 km grid cells and modelled annual cholera incidence in each grid cell assuming a Poisson process adjusted for covariates and spatially correlated random effects. We combined these findings with data on population distribution to estimate the number of people living in areas of high cholera incidence (>1 case per 1000 people per year). We further estimated the reduction in cholera incidence that could be achieved by targeting cholera prevention and control interventions at areas of high cholera incidence., Findings: We included 279 datasets covering 2283 locations in our analyses. In sub-Saharan Africa (excluding Djibouti and Eritrea), a mean of 141 918 cholera cases (95% credible interval [CrI] 141 538-146 505) were reported per year. 4·0% (95% CrI 1·7-16·8) of districts, home to 87·2 million people (95% CrI 60·3 million to 118·9 million), have high cholera incidence. By focusing on the highest incidence districts first, effective targeted interventions could eliminate 50% of the region's cholera by covering 35·3 million people (95% CrI 26·3 million to 62·0 million), which is less than 4% of the total population., Interpretation: Although cholera occurs throughout sub-Saharan Africa, its highest incidence is concentrated in a small proportion of the continent. Prioritising high-risk areas could substantially increase the efficiency of cholera control programmes., Funding: The Bill & Melinda Gates Foundation., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Oral cholera vaccines are primarily recommended by the World Health Organization for cholera control in endemic countries. However, the number of cholera vaccines currently produced is very limited and examples of OCV use in endemic countries, and especially in urban settings, are scarce. A vaccination campaign was organized by Médecins Sans Frontières and the Ministry of Health in a highly endemic area in the Democratic Republic of Congo. This study aims to describe the vaccine coverage achieved with this highly targeted vaccination campaign and the acceptability among the vaccinated communities., Methods and Findings: We performed a cross-sectional survey using random spatial sampling. The study population included individuals one year old and above, eligible for vaccination, and residing in the areas targeted for vaccination in the city of Kalemie. Data sources were household interviews with verification by vaccination card. In total 2,488 people were included in the survey. Overall, 81.9% (95%CI: 77.9-85.3) of the target population received at least one dose of vaccine. The vaccine coverage with two doses was 67.2% (95%CI: 61.9-72.0) among the target population. The vaccine coverage was higher during the first round (74.0, 95%CI: 69.3-78.3) than during the second round of vaccination (69.1%, 95%CI: 63.9-74.0). Vaccination coverage was lower in male adults. The main reason for non-vaccination was to be absent during the campaign. No severe adverse events were notified during the interviews., Conclusions: Cholera vaccination campaigns using highly targeted strategies are feasible in urban settings. High vaccination coverage can be obtained using door to door vaccination. However, alternative strategies should be considered to reach non-vaccinated populations like male adults and also in order to improve the efficiency of the interventions., Competing Interests: Some MSF field representatives who coordinated the data collection were involved in the preparation of the manuscript but not in the analysis. There are no other competing interests.

Background: Cholera burden in Africa remains unknown, often because of weak national surveillance systems. We analyzed data from the African Cholera Surveillance Network (www.africhol.org)., Methods/ Principal Findings: During June 2011-December 2013, we conducted enhanced surveillance in seven zones and four outbreak sites in Togo, the Democratic Republic of Congo (DRC), Guinea, Uganda, Mozambique and Cote d'Ivoire. All health facilities treating cholera cases were included. Cholera incidences were calculated using culture-confirmed cholera cases and culture-confirmed cholera cases corrected for lack of culture testing usually due to overwhelmed health systems and imperfect test sensitivity. Of 13,377 reported suspected cases, 34% occurred in Conakry, Guinea, 47% in Goma, DRC, and 19% in the remaining sites. From 0-40% of suspected cases were aged under five years and from 0.3-86% had rice water stools. Within surveillance zones, 0-37% of suspected cases had confirmed cholera compared to 27-38% during outbreaks. Annual confirmed incidence per 10,000 population was <0.5 in surveillance zones, except Goma where it was 4.6. Goma and Conakry had corrected incidences of 20.2 and 5.8 respectively, while the other zones a median of 0.3. During outbreaks, corrected incidence varied from 2.6 to 13.0. Case fatality ratios ranged from 0-10% (median, 1%) by country., Conclusions/significance: Across different African epidemiological contexts, substantial variation occurred in cholera incidence, age distribution, clinical presentation, culture confirmation, and testing frequency. These results can help guide preventive activities, including vaccine use.

Background: Since cholera appeared in Africa during the 1970s, cases have been reported on the continent every year. In Sub-Saharan Africa, cholera outbreaks primarily cluster at certain hotspots including the African Great Lakes Region and West Africa., Methodology/principal Findings: In this study, we applied MLVA (Multi-Locus Variable Number Tandem Repeat Analysis) typing of 337 Vibrio cholerae isolates from recent cholera epidemics in the Democratic Republic of the Congo (DRC), Zambia, Guinea and Togo. We aimed to assess the relationship between outbreaks. Applying this method, we identified 89 unique MLVA haplotypes across our isolate collection. MLVA typing revealed the short-term divergence and microevolution of these Vibrio cholerae populations to provide insight into the dynamics of cholera outbreaks in each country. Our analyses also revealed strong geographical clustering. Isolates from the African Great Lakes Region (DRC and Zambia) formed a closely related group, while West African isolates (Togo and Guinea) constituted a separate cluster. At a country-level scale our analyses revealed several distinct MLVA groups, most notably DRC 2011/2012, DRC 2009, Zambia 2012 and Guinea 2012. We also found that certain MLVA types collected in the DRC persisted in the country for several years, occasionally giving rise to expansive epidemics. Finally, we found that the six environmental isolates in our panel were unrelated to the epidemic isolates., Conclusions/significance: To effectively combat the disease, it is critical to understand the mechanisms of cholera emergence and diffusion in a region-specific manner. Overall, these findings demonstrate the relationship between distinct epidemics in West Africa and the African Great Lakes Region. This study also highlights the importance of monitoring and analyzing Vibrio cholerae isolates.

We evaluated published and unpublished data on cholera cases and deaths reported from clinical care facilities in the 56 health districts of the Democratic Republic of Congo to the National Ministry of Health during 2000-2011. Cholera incidence was highest in the eastern provinces bordering lakes and epidemics primarily originated in this region. Along with a strong seasonal component, our data suggest a potential Vibrio cholerae reservoir in the Rift Valley lakes and the possible contribution of the lakes' fishing industry to the spread of cholera. The National Ministry of Health has committed to the elimination-rather than control-of cholera in DRC and has adopted a new national policy built on improved alert, response, case management, and prevention. To achieve this goal and implement all these measures it will require strong partners in the international community with a similar vision.

Background: Cholera is an endemic disease in certain well-defined areas in the east of the Democratic Republic of Congo (DRC). The west of the country, including the mega-city Kinshasa, has been free of cases since mid 2001 when the last outbreak ended., Methods and Findings: We used routinely collected passive surveillance data to construct epidemic curves of the cholera cases and map the spatio-temporal progress of the disease during the first 47 weeks of 2011. We compared the spatial distribution of disease spread to that which occurred in the last cholera epidemic in Kinshasa between 1996 and 2001. To better understand previous determinants of cholera spread in this region, we conducted a correlation analysis to assess the impact of rainfall on weekly health zone cholera case counts between December 1998 and March 2001 and a Generalized Linear Model (GLM) regression analysis to identify factors that have been associated with the most vulnerable health zones within Kinshasa between October 1998 and June 1999. In February 2011, cholera reemerged in a region surrounding Kisangani and gradually spread westwards following the course of the Congo River to Kinshasa, home to 10 million people. Ten sampled isolates were confirmed to be Vibrio cholerae O1, biotype El Tor, serotype Inaba, resistant to trimethoprim-sulfa, furazolidone, nalidixic acid, sulfisoxaole, and streptomycin, and intermediate resistant to Chloramphenicol. An analysis of a previous outbreak in Kinshasa shows that rainfall was correlated with case counts and that health zone population densities as well as fishing and trade activities were predictors of case counts., Conclusion: Cholera is particularly difficult to tackle in the DRC. Given the duration of the rainy season and increased riverine traffic from the eastern provinces in late 2011, we expect further increases in cholera in the coming months and especially within the mega-city Kinshasa. We urge all partners involved in the response to remain alert.Didier Bompangue and Silvan Vesenbeckh contributed equally to this work. *corresponding author: Silvan Vesenbeckh, Harvard School of Public Health (vesenbeckh@gmail.com)Didier Bompangue is Associate Professor in the Department of Microbiology (University of Kinshasa) andEpidemiologist in the DRC Ministry of Health. He was involved in the investigations of the described outbreak since February 2011.

Background: During the last eight years, North and South Kivu, located in a lake area in Eastern Democratic Republic of Congo, have been the site of a major volcano eruption and of numerous complex emergencies with population displacements. These conditions have been suspected to favour emergence and spread of cholera epidemics., Methodology/principal Findings: In order to assess the influence of these conditions on outbreaks, reports of cholera cases were collected weekly from each health district of North Kivu (4,667,699 inhabitants) and South Kivu (4,670,121 inhabitants) from 2000 through 2007. A geographic information system was established, and in each health district, the relationships between environmental variables and the number of cholera cases were assessed using regression techniques and time series analysis. We further checked for a link between complex emergencies and cholera outbreaks. Finally, we analysed data collected during an epidemiological survey that was implemented in Goma after Nyiragongo eruption. A total of 73,605 cases and 1,612 deaths of cholera were reported. Time series decomposition showed a greater number of cases during the rainy season in South Kivu but not in North Kivu. Spatial distribution of cholera cases exhibited a higher number of cases in health districts bordering lakes (Odds Ratio 7.0, Confidence Interval range 3.8-12.9). Four epidemic reactivations were observed in the 12-week periods following war events, but simulations indicate that the number of reactivations was not larger than that expected during any random selection of period with no war. Nyiragongo volcanic eruption was followed by a marked decrease of cholera incidence., Conclusion/significance: Our study points out the crucial role of some towns located in lakeside areas in the persistence of cholera in Kivu. Even if complex emergencies were not systematically followed by cholera epidemics, some of them enabled cholera spreading.