Research Article: Updated Global Burden of Cholera in Endemic Countries

Date Published: June 4, 2015

Publisher: Public Library of Science

Author(s): Mohammad Ali, Allyson R. Nelson, Anna Lena Lopez, David A. Sack, Justin V. Remais.

Abstract: BackgroundThe global burden of cholera is largely unknown because the majority of cases are not reported. The low reporting can be attributed to limited capacity of epidemiological surveillance and laboratories, as well as social, political, and economic disincentives for reporting. We previously estimated 2.8 million cases and 91,000 deaths annually due to cholera in 51 endemic countries. A major limitation in our previous estimate was that the endemic and non-endemic countries were defined based on the countries’ reported cholera cases. We overcame the limitation with the use of a spatial modelling technique in defining endemic countries, and accordingly updated the estimates of the global burden of cholera.Methods/Principal FindingsCountries were classified as cholera endemic, cholera non-endemic, or cholera-free based on whether a spatial regression model predicted an incidence rate over a certain threshold in at least three of five years (2008-2012). The at-risk populations were calculated for each country based on the percent of the country without sustainable access to improved sanitation facilities. Incidence rates from population-based published studies were used to calculate the estimated annual number of cases in endemic countries. The number of annual cholera deaths was calculated using inverse variance-weighted average case-fatality rate (CFRs) from literature-based CFR estimates. We found that approximately 1.3 billion people are at risk for cholera in endemic countries. An estimated 2.86 million cholera cases (uncertainty range: 1.3m-4.0m) occur annually in endemic countries. Among these cases, there are an estimated 95,000 deaths (uncertainty range: 21,000-143,000).Conclusion/SignificanceThe global burden of cholera remains high. Sub-Saharan Africa accounts for the majority of this burden. Our findings can inform programmatic decision-making for cholera control.

Partial Text: Since the early 1800s, pandemics of cholera have affected millions, with the seventh still ongoing since 1961 [1]. Access to safe water and improved sanitation facilities has eliminated cholera transmission of Vibrio cholerae, the causative agent, in high-income countries. However, the bacteria continue to afflict millions of people in less developed countries where improved water and sanitation infrastructure are not widely available.

We estimate that there were 2.9 million cases (uncertainty range: 1.3 to 4.0 million) of cholera annually in 69 cholera-endemic countries and 95,000 deaths (uncertainty range: 21,000–143,000) between 2008 and 2012. The total estimates are similar to the global burden estimates from 2000–2008 [6], however the distribution is different. Our study showed that Sub-Saharan Africa accounted for 60% and South-East Asia accounted for 29% of the global burden of cholera cases between 2008 and 2012. Our findings highlight the fact that cholera remains an important public health issue in more than one-third of the countries of world.



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