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Cholera at the Crossroads: The Association Between Endemic Cholera and National Access to Improved Water Sources and Sanitation
Benjamin L. Nygren
Benjamin L. Nygren
Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Anna J. Blackstock
Anna J. Blackstock
Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Eric D. Mintz
Eric D. Mintz
Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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We evaluated World Health Organization (WHO) national water and sanitation coverage levels and the infant mortality rate as predictors of endemic cholera in the 5-year period following water and sanitation coverage estimates using logistic regression, receiver operator characteristic curves, and different definitions of endemicity. Each was a significant predictors of endemic cholera at P < 0.001. Using a value of 250 for annual cases reported in 3 of 5 years, a national water access level of 71% has 65% sensitivity and 65% specificity in predicting endemic cholera, a sanitation access level of 39% has 63% sensitivity and 62% specificity, and an infant mortality rate of 65/1,000 has 67% sensitivity and 69% specificity. Our findings reveal the tradeoff between sensitivity and specificity for these predictors of endemic cholera and highlight the substantial uncertainty in the data. More accurate global surveillance data will enable more precise characterization of the benefits of improved water and sanitation.
Author Notes
Financial support: This work was supported in part by the United States Agency for International Development.
Authors' addresses: Benjamin L. Nygren, Anna J. Blackstock, and Eric D. Mintz, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: bnygren@cdc.gov, hyp9@cdc.gov, and emintz@cdc.gov.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
United Nations Department of Public Information (UNDoP), 2013. Millennium Development Goals and Beyond 2015: Fact Sheet, 1–2.
-
2.
WHO, 2013. Progress on Sanitation and Drinking-Water - 2013 update, 3–13.
-
3.
Ackers ML, Quick RE, Drasbek CJ, Hutwagner L, Tauxe RV, 1998. Are there national risk factors for epidemic cholera? The correlation between socioeconomic and demographic indices and cholera incidence in Latin America. Int J Epidemiol 27: 330–334.
-
4.
WHO, 2013. Global Health Observatory (GHO) Data Repository. Available at: http://www.who.int/gho/database/en/. Accessed April 1, 2014.
-
5.
Ali M, Lopez AL, You YA, Kim YE, Sah B, Maskery B, Clemens J, 2012. The global burden of cholera. Bull World Health Organ 90: 209–218A.
-
6.
WHO. Indicator Definition: Population Using Improved Drinking-Water Sources (%). Available at: http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=8. Accessed April 1, 2014.
-
7.
WHO. Indicator Definition: Population Using Improved Sanitation Facilities (%). Available at: http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=9. Accessed April 1, 2014.
-
8.
WHO. Indicator Definition: Infant Mortality Rate. Available at: http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=1. Accessed April 1, 2014.
-
9.
WHO. Indicator Definition: Number of Reported Cases of Cholera. Available at: http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=42. Accessed April 1, 2014.
-
10.
WHO. Indicator Definition: Number of Reported Deaths of Cholera. Available at: http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=2446. Accessed April 1, 2014.
-
11.
WHO, 2009. Meeting of the Strategic Advisory Group of Experts on immunization, October 2009: conclusions and recommendations. Wkly Epidemiol Rec 84: 526–528.
-
12.
WHO, 2010. Cholera vaccines: WHO position paper. Wkly Epidemiol Rec 85: 127.
-
13.
WHO, 2013. Progress on Sanitation and Drinking-Water - 2012 update, 4.
-
14.
UNICEF, 2011. United Nations Inter-Agency Group for Child Mortality Estimation: Levels and Trends in Child Mortlity. New York: UNICEF.
-
15.
Bwire G, Malimbo M, Maskery B, Kim YE, Mogasale V, Levin A, 2013. The burden of cholera in Uganda. PLoS Negl Trop Dis 7: e2545.
-
16.
Sarkar BL, Kanungo S, Nair GB, 2012. How endemic is cholera in India? Indian J Med Res 135: 246–248.
-
17.
Griffith DC, Kelly-Hope LA, Miller MA, 2006. Review of reported cholera outbreaks worldwide, 1995–2005. Am J Trop Med Hyg 75: 973–977.
-
18.
WHO, 2000. WHO Report on Global Surveillance of Epidemic-prone Infectious Diseases.
-
19.
WHO, 2009. Cholera: global surveillance summary, 2008. Wkly Epidemiol Rec 84: 309–324.
-
20.
WHO, 2014. Cholera Surveillance and Number of Cases. Available at: http://www.who.int/topics/cholera/surveillance/en/. Accessed April 1, 2014.
| Past two years | Past Year | Past 30 Days | |
|---|---|---|---|
| Abstract Views | 583 | 536 | 30 |
| Full Text Views | 349 | 12 | 0 |
| PDF Downloads | 92 | 7 | 0 |