Publications by authors named "Dominique Legros"

51 Publications

COVID-19 and traumatic stress: The role of perceived vulnerability, COVID-19-related worries, and social isolation.

J Anxiety Disord 2020 12 8;76:102307. Epub 2020 Sep 8.

Department of Psychology, Pace University, New York, NY, United States.

The purpose of the present study was to propose and test two models to understand the relationship between perceived vulnerability to COVID-19 (PVC) and COVID-19-related traumatic stress (TS), as well as the variables that may mediate and moderate this relationship among individuals who have not yet been infected with COVID-19. Using an online survey, data were collected between late March and early April 2020. Participants were recruited through Amazon Mechanical Turk and included 747 adults living in the United States. Supporting our hypotheses, results indicated that both COVID-19-related worries and social isolation were significant mediators of the relationship between PVC and TS (Model 1). In addition, the results of a moderated mediation analysis indicated that the indirect effect of PVC on TS through COVID-19-related worries was stronger for participants who reported greater social isolation (Model 2). Although future research is needed, these findings suggest that both social isolation and disease-related worries may be important variables that can be targeted in interventions to reduce pandemic-related TS.
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http://dx.doi.org/10.1016/j.janxdis.2020.102307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831572PMC
December 2020

Self-criticism, self-compassion, and perceived health: moderating effect of ethnicity.

J Gen Psychol 2020 Apr 3:1-19. Epub 2020 Apr 3.

Private Practice.

A caring and compassionate attitude toward the self (i.e., self-compassion) has been linked to various mental and physical health benefits. The Self-Compassion Scale (SCS) is widely used in psychology literature in order to assess global self-compassion. However, recent evidence suggests that the single factor model comprising positive and negative items of the SCS in fact measures two distinct constructs (i.e., self-criticism/self-coldness and self-compassion) with different psychological correlates. Given these recent findings, in addition to other research that highlights cultural differences in self-conceptualizations and self-evaluations, the present study examined potential ethnic differences in the relationships between self-criticism, self-compassion, and perceived health. Participants included 728 college students (141 Asian American, 449 European American, and 138 Hispanic/Latinx individuals) attending a university in the northeast United States. Results indicated that the relationship between self-criticism and self-compassion was significantly different across ethnicity. In addition, the relationships between these two constructs (i.e., self-criticism and self-compassion) and perceived health were moderated by ethnicity. Our findings suggest that focusing on global self-compassion scores (i.e., total SCS scores) may miss some of the important cultural or ethnic differences in the relationships between self-criticism, self-compassion, and perceived health.
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http://dx.doi.org/10.1080/00221309.2020.1746232DOI Listing
April 2020

Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: A scoping review of current international guidelines.

PLoS One 2020 8;15(1):e0226549. Epub 2020 Jan 8.

Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.

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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0226549PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948749PMC
April 2020

Cholera surveillance and estimation of burden of cholera.

Vaccine 2020 02 17;38 Suppl 1:A13-A17. Epub 2019 Jul 17.

The Global Task Force on Cholera Control, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland. Electronic address:

Cholera continues to be poorly controlled in multiple epidemic and endemic areas across the globe, with estimated annual incidence of 1.3-4.0 million cases, resulting in 21,000 to 143,000 deaths worldwide in 2015. The usual approach for patient diagnosis and cholera surveillance is clinical examination of cases of acute watery diarrhea (AWD), confirmed by positive culture or polymerase chain reaction tests. Rapid diagnostic tests (RDTs) are used in regions with limited laboratory capacities but have been found to demonstrate large variations in performance, ranging in sensitivity from 58% to 100% and in specificity from 60% to 100%. Most countries rely on hospital-based surveillance of diarrheal disease to compute the cholera burden. The World Health Organization (WHO) recommends that countries assess public health events involving cholera against the International Health Regulations 2005 criteria and determine need for official notification using the standard case definition. Cholera is an often under-recognized and under reported problem because of differences in case definitions, reluctance by authorities to acknowledge and report cholera, inadequacies in hospital surveillance systems, lack of effective diagnostic tests and commonalities in clinical presentation of cholera with other AWD etiologies. The resulting gap in burden data impairs economic analysis of disease impact and identification of areas for targeted control interventions. There is an urgent need to strengthen surveillance data by supplementing reported numbers with estimates from literature reviews and data from modelling studies, developing better-performing RDTs, enhancing monitoring and evaluation processes of in-country surveillance systems, and encouraging countries to report cholera cases by "rewarding" better reporting with technical support and improved access to vaccines. It is imperative that immediate steps are taken towards strengthening surveillance and reporting systems globally, especially in cholera-prone and resource-limited areas, where it will enable countries to articulate their demand for resources more accurately.
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http://dx.doi.org/10.1016/j.vaccine.2019.07.036DOI Listing
February 2020

Cholera prevention and control in refugee settings: Successes and continued challenges.

PLoS Negl Trop Dis 2019 06 20;13(6):e0007347. Epub 2019 Jun 20.

Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America.

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http://dx.doi.org/10.1371/journal.pntd.0007347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586254PMC
June 2019

Cholera prevention and control in Asian countries.

BMC Proc 2018 7;12(Suppl 13):62. Epub 2018 Dec 7.

26World Health Organization, New Delhi, India.

Cholera remains a major public health problem in many countries. Poor sanitation and inappropriate clean water supply, insufficient health literacy and community mobilization, absence of national plans and cross-border collaborations are major factors impeding optimal control of cholera in endemic countries. In March 2017, a group of experts from 10 Asian cholera-prone countries that belong to the Initiative against Diarrheal and Enteric Diseases in Africa and Asia (IDEA), together with representatives from the World Health Organization, the US National Institutes of Health, International Vaccine Institute, Agence de médecine préventive, NGOs (Save the Children) and UNICEF, met in Hanoi (Vietnam) to share progress in terms of prevention and control interventions on water, sanitation and hygiene (WASH), surveillance and oral cholera vaccine use. This paper reports on the country situation, gaps identified in terms of cholera prevention and control and strategic interventions to bridge these gaps.
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http://dx.doi.org/10.1186/s12919-018-0158-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6284268PMC
December 2018

Global Cholera Epidemiology: Opportunities to Reduce the Burden of Cholera by 2030.

J Infect Dis 2018 10;218(suppl_3):S137-S140

World Health Organization, Geneva, Switzerland.

While safe drinking water and advanced sanitation systems have made the Global North cholera-free for decades, the disease still affects 47 countries across the globe resulting in an estimated 2.86 million cases and 95,000 deaths per year worldwide. Cholera impacts communities already burdened by conflict, lack of infrastructure, poor health systems, and malnutrition. In October 2017, the Global Task Force on Cholera Control (GTFCC) launched an initiative titled Ending Cholera: A Global Roadmap to 2030, with the objective to reduce cholera deaths by 90% worldwide, and eliminate cholera in at least 20 countries by 2030. The GTFCC is working to position cholera control not as a vertical programme but instead using cholera as a marker of inequity and an indicator of poverty, linking the objectives of the Roadmap to the SDGs. The roadmap consists of targeted multi-sectoral interventions, supported by a coordination mechanism, along 3 axes: (1) early detection and quick response to contain outbreaks; (2) a multisectoral approach to prevent cholera recurrence in hotspots; (3) an effective partnership mechanism of coordination for technical support, countries capacity building, research and M&E, advocacy and resource mobilization. Every case and every death from cholera is preventable with the tools we have today.
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http://dx.doi.org/10.1093/infdis/jiy486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207143PMC
October 2018

Mapping the burden of cholera in sub-Saharan Africa and implications for control: an analysis of data across geographical scales.

Lancet 2018 05 1;391(10133):1908-1915. Epub 2018 Mar 1.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Médecins sans Frontières, Geneva, Switzerland.

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.
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http://dx.doi.org/10.1016/S0140-6736(17)33050-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946088PMC
May 2018

Oral cholera vaccine coverage in hard-to-reach fishermen communities after two mass Campaigns, Malawi, 2016.

Vaccine 2017 09 10;35(38):5194-5200. Epub 2017 Aug 10.

Ministry of Health, Community Health Sciences Unit, Lilongwe, Malawi. Electronic address:

Context: From December 2015 to August 2016, a large epidemic of cholera affected the fishermen of Lake Chilwa in Malawi. A first reactive Oral Cholera Vaccines (OCV) campaign was organized, in February, in a 2km radius of the lake followed by a preemptive one, conducted in November, in a 25km radius. We present the vaccine coverage reached in hard-to-reach population using simplified delivery strategies.

Method: We conducted two-stage random-sampling cross-sectional surveys among individuals living in a 2km and 25km radius of Lake Chilwa (islands and floating homes included). Individuals aged 12months and older from Machinga and Zomba districts were sampled: 43 clusters of 14 households were surveyed. Simplified strategies were used for those living in islands and floating homes: self- delivery and community-supervised delivery of the second dose. Vaccine coverage (VC) for at-least-two-doses was estimated taking into account sampling weights and design effects.

Results: A total of 1176 households were surveyed (2.7% of non-response). Among the 2833 individuals living in the 2km radius of Lake and the 2915 in the 25km radius: 457 (16.1%) and 239 (8.2%) lived in floating homes or on islands at some point in the year, respectively. For the overall population, VC was 75.6% and 54.2%, respectively. In the 2km radius, VC was 92.2% for those living on the lake at some point of the year: 271 (64.8%) used the simplified strategies. The main reasons for non-vaccination were absence during the campaign and vaccine shortage. Few adverse events occurring in the 24h following vaccination was reported.

Conclusions: We reached a high two-dose coverage of the most at-risk population using simplified delivery strategies. Because of the high fishermen mobility, regular catch-up campaigns or another strategy specifically targeting fishermen need to be assessed for more efficient vaccines use.
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http://dx.doi.org/10.1016/j.vaccine.2017.07.104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594244PMC
September 2017

Protection against cholera from killed whole-cell oral cholera vaccines: a systematic review and meta-analysis.

Lancet Infect Dis 2017 10 17;17(10):1080-1088. Epub 2017 Jul 17.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Médecins Sans Frontières, Geneva, Switzerland. Electronic address:

Background: Killed whole-cell oral cholera vaccines (kOCVs) are becoming a standard cholera control and prevention tool. However, vaccine efficacy and direct effectiveness estimates have varied, with differences in study design, location, follow-up duration, and vaccine composition posing challenges for public health decision making. We did a systematic review and meta-analysis to generate average estimates of kOCV efficacy and direct effectiveness from the available literature.

Methods: For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and the Cochrane Review Library on July 9, 2016, and ISI Web of Science on July 11, 2016, for randomised controlled trials and observational studies that reported estimates of direct protection against medically attended confirmed cholera conferred by kOCVs. We included studies published on any date in English, Spanish, French, or Chinese. We extracted from the published reports the primary efficacy and effectiveness estimates from each study and also estimates according to number of vaccine doses, duration, and age group. The main study outcome was average efficacy and direct effectiveness of two kOCV doses, which we estimated with random-effect models. This study is registered with PROSPERO, number CRD42016048232.

Findings: Seven trials (with 695 patients with cholera) and six observational studies (217 patients with cholera) met the inclusion criteria, with an average two-dose efficacy of 58% (95% CI 42-69, I=58%) and effectiveness of 76% (62-85, I=0). Average two-dose efficacy in children younger than 5 years (30% [95% CI 15-42], I=0%) was lower than in those 5 years or older (64% [58-70], I=0%; p<0·0001). Two-dose efficacy estimates of kOCV were similar during the first 2 years after vaccination, with estimates of 56% (95% CI 42-66, I=45%) in the first year and 59% (49-67, I=0) in the second year. The efficacy reduced to 39% (13 to 57, I=48%) in the third year, and 26% (-46 to 63, I=74%) in the fourth year.

Interpretation: Two kOCV doses provide protection against cholera for at least 3 years. One kOCV dose provides at least short-term protection, which has important implications for outbreak management. kOCVs are effective tools for cholera control.

Funding: The Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S1473-3099(17)30359-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5639147PMC
October 2017

El Niño and the shifting geography of cholera in Africa.

Proc Natl Acad Sci U S A 2017 04 10;114(17):4436-4441. Epub 2017 Apr 10.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205;

The El Niño Southern Oscillation (ENSO) and other climate patterns can have profound impacts on the occurrence of infectious diseases ranging from dengue to cholera. In Africa, El Niño conditions are associated with increased rainfall in East Africa and decreased rainfall in southern Africa, West Africa, and parts of the Sahel. Because of the key role of water supplies in cholera transmission, a relationship between El Niño events and cholera incidence is highly plausible, and previous research has shown a link between ENSO patterns and cholera in Bangladesh. However, there is little systematic evidence for this link in Africa. Using high-resolution mapping techniques, we find that the annual geographic distribution of cholera in Africa from 2000 to 2014 changes dramatically, with the burden shifting to continental East Africa-and away from Madagascar and portions of southern, Central, and West Africa-where almost 50,000 additional cases occur during El Niño years. Cholera incidence during El Niño years was higher in regions of East Africa with increased rainfall, but incidence was also higher in some areas with decreased rainfall, suggesting a complex relationship between rainfall and cholera incidence. Here, we show clear evidence for a shift in the distribution of cholera incidence throughout Africa in El Niño years, likely mediated by El Niño's impact on local climatic factors. Knowledge of this relationship between cholera and climate patterns coupled with ENSO forecasting could be used to notify countries in Africa when they are likely to see a major shift in their cholera risk.
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http://dx.doi.org/10.1073/pnas.1617218114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5410791PMC
April 2017

Achievements and challenges for the use of killed oral cholera vaccines in the global stockpile era.

Hum Vaccin Immunother 2017 03;13(3):579-587

a World Health Organization , Geneva , Switzerland.

Cholera remains an important but neglected public health threat, affecting the health of the poorest populations and imposing substantial costs on public health systems. Cholera can be eliminated where access to clean water, sanitation, and satisfactory hygiene practices are sustained, but major improvements in infrastructure continue to be a distant goal. New developments and trends of cholera disease burden, the creation of affordable oral cholera vaccines (OCVs) for use in developing countries, as well as recent evidence of vaccination impact has created an increased demand for cholera vaccines. The global OCV stockpile was established in 2013 and with support from Gavi, has assisted in achieving rapid access to vaccine in emergencies. Recent WHO prequalification of a second affordable OCV supports the stockpile goals of increased availability and distribution to affected populations. It serves as an essential step toward an integrated cholera control and prevention strategy in emergency and endemic settings.
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http://dx.doi.org/10.1080/21645515.2016.1245250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360144PMC
March 2017

Immune Responses to an Oral Cholera Vaccine in Internally Displaced Persons in South Sudan.

Sci Rep 2016 10 24;6:35742. Epub 2016 Oct 24.

Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA.

Despite recent large-scale cholera outbreaks, little is known about the immunogenicity of oral cholera vaccines (OCV) in African populations, particularly among those at highest cholera risk. During a 2015 preemptive OCV campaign among internally displaced persons in South Sudan, a year after a large cholera outbreak, we enrolled 37 young children (1-5 years old), 67 older children (6-17 years old) and 101 adults (≥18 years old), who received two doses of OCV (Shanchol) spaced approximately 3 weeks apart. Cholera-specific antibody responses were determined at days 0, 21 and 35 post-immunization. High baseline vibriocidal titers (>80) were observed in 21% of the participants, suggesting recent cholera exposure or vaccination. Among those with titers ≤80, 90% young children, 73% older children and 72% adults seroconverted (≥4 fold titer rise) after the 1 OCV dose; with no additional seroconversion after the 2 dose. Post-vaccination immunological endpoints did not differ across age groups. Our results indicate Shanchol was immunogenic in this vulnerable population and that a single dose alone may be sufficient to achieve similar short-term immunological responses to the currently licensed two-dose regimen. While we found no evidence of differential response by age, further immunologic and epidemiologic studies are needed.
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http://dx.doi.org/10.1038/srep35742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5075787PMC
October 2016

Feasibility and acceptability of oral cholera vaccine mass vaccination campaign in response to an outbreak and floods in Malawi.

Pan Afr Med J 2016 20;23:203. Epub 2016 Apr 20.

World Health Organization, Geneva, Switzerland.

Introduction: Despite some improvement in provision of safe drinking water, proper sanitation and hygiene promotion, cholera still remains a major public health problem in Malawi with outbreaks occurring almost every year since 1998. In response to 2014/2015 cholera outbreak, ministry of health and partners made a decision to assess the feasibility and acceptability of conducting a mass oral cholera vaccine (OCV) as an additional public health measure. This paper highlights the burden of the 2014/15 cholera outbreak, successes and challenges of OCV campaign conducted in March and April 2015.

Methods: This was a documentation of the first OCV campaign conducted in Malawi. The campaign targeted over 160,000 people aged one year or more living in 19 camps of people internally displaced by floods and their surrounding communities in Nsanje district. It was a reactive campaign as additional measure to improved water, sanitation and hygiene in response to the laboratory confirmed cholera outbreak.

Results: During the first round of the OCV campaign conducted from 30 March to 4 April 2015, a total of 156,592 (97.6%) people out of 160,482 target population received OCV. During the second round (20 to 25 April 2015), a total of 137,629 (85.8%) people received OCV. Of these, 108,247 (67.6%) people received their second dose while 29,382 (18.3%) were their first dose. Of the 134,836 people with known gender and sex who received 1 or 2 doses, 54.4% were females and over half (55.4%) were children under the age of 15 years. Among 108,237 people who received 2 doses (fully immunized), 54.4% were females and 51.9% were children under 15 years of age. No severe adverse event following immunization was reported. The main reason for non-vaccination or failure to take the 2 doses was absence during the period of the campaign.

Conclusion: This documentation has demonstrated that it was feasible, acceptable by the community to conduct a large-scale mass OCV campaign in Malawi within five weeks. Of 320,000 OCV doses received, Malawi managed to administer at least 294,221 (91.9%) of the doses. OCV could therefore be considered to be introduced as additional measure in cholera hot spot areas in Malawi.
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http://dx.doi.org/10.11604/pamj.2016.23.203.8346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907756PMC
February 2017

Population-Level Effect of Cholera Vaccine on Displaced Populations, South Sudan, 2014.

Emerg Infect Dis 2016 06;22(6):1067-70

Following mass population displacements in South Sudan, preventive cholera vaccination campaigns were conducted in displaced persons camps before a 2014 cholera outbreak. We compare cholera transmission in vaccinated and unvaccinated areas and show vaccination likely halted transmission within vaccinated areas, illustrating the potential for oral cholera vaccine to stop cholera transmission in vulnerable populations.
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http://dx.doi.org/10.3201/eid2206.151592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880069PMC
June 2016

Safe water, sanitation, hygiene, and a cholera vaccine.

Lancet 2016 Jan;387(10013):28

Centers for Disease Control and Prevention, Atlanta, GA, USA.

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http://dx.doi.org/10.1016/S0140-6736(15)01294-5DOI Listing
January 2016

Outbreaks of cholera in the time of Ebola: pre-emptive action needed.

Lancet 2015 Mar 20;385(9971):851. Epub 2015 Feb 20.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

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http://dx.doi.org/10.1016/S0140-6736(15)60178-7DOI Listing
March 2015

Post-licensure deployment of oral cholera vaccines: a systematic review.

Bull World Health Organ 2014 Dec 29;92(12):881-93. Epub 2014 Sep 29.

Delivering Oral Vaccine Effectively (DOVE), Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, United States of America (USA).

Objective: To describe and analyse the characteristics of oral cholera vaccination campaigns; including location, target population, logistics, vaccine coverage and delivery costs.

Methods: We searched PubMed, the World Health Organization (WHO) website and the Cochrane database with no date or language restrictions. We contacted public health personnel, experts in the field and in ministries of health and did targeted web searches.

Findings: A total of 33 documents were included in the analysis. One country, Viet Nam, incorporates oral cholera vaccination into its public health programme and has administered approximately 10.9 million vaccine doses between 1997 and 2012. In addition, over 3 million doses of the two WHO pre-qualified oral cholera vaccines have been administered in more than 16 campaigns around the world between 1997 and 2014. These campaigns have either been pre-emptive or reactive and have taken place under diverse conditions, such as in refugee camps or natural disasters. Estimated two-dose coverage ranged from 46 to 88% of the target population. Approximate delivery cost per fully immunized person ranged from 0.11-3.99 United States dollars.

Conclusion: Experience with oral cholera vaccination campaigns continues to increase. Public health officials may draw on this experience and conduct oral cholera vaccination campaigns more frequently.
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http://dx.doi.org/10.2471/BLT.14.139949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264394PMC
December 2014

Use of Vibrio cholerae vaccine in an outbreak in Guinea.

N Engl J Med 2014 May;370(22):2111-20

From Epicentre (F.J.L., L.G., A.-L.P., R.F.G.), African Cholera Surveillance Network, Agence de Médicine Préventive (K.S., M.A.M.), and National Reference Center for Vibrios and Cholera, Enteric Bacterial Pathogens Research and Expertise Unit, Institut Pasteur (M.-L.Q.) - all in Paris; Médecins sans Frontières, Geneva (L.G., I.C., M.S., D.L.); Ministry of Health (K.S.), Direction Préfectorale de la Santé (B.T.) and Research and Documentation Service, Ministry of Health (A.A.D.), Médecins sans Frontières (M.H.), and World Health Organization (C.I.) - all in Conakry, Guinea; and the Department of Microbiology, University of Valladolid, Valladolid, Spain (J.M.E.).

Background: The use of vaccines to prevent and control cholera is currently under debate. Shanchol is one of the two oral cholera vaccines prequalified by the World Health Organization; however, its effectiveness under field conditions and the protection it confers in the first months after administration remain unknown. The main objective of this study was to estimate the short-term effectiveness of two doses of Shanchol used as a part of the integrated response to a cholera outbreak in Africa.

Methods: We conducted a matched case-control study in Guinea between May 20 and October 19, 2012. Suspected cholera cases were confirmed by means of a rapid test, and controls were selected among neighbors of the same age and sex as the case patients. The odds of vaccination were compared between case patients and controls in bivariate and adjusted conditional logistic-regression models. Vaccine effectiveness was calculated as (1-odds ratio)×100.

Results: Between June 8 and October 19, 2012, we enrolled 40 case patients and 160 controls in the study for the primary analysis. After adjustment for potentially confounding variables, vaccination with two complete doses was associated with significant protection against cholera (effectiveness, 86.6%; 95% confidence interval, 56.7 to 95.8; P=0.001).

Conclusions: In this study, Shanchol was effective when used in response to a cholera outbreak in Guinea. This study provides evidence supporting the addition of vaccination as part of the response to an outbreak. It also supports the ongoing efforts to establish a cholera vaccine stockpile for emergency use, which would enhance outbreak prevention and control strategies. (Funded by Médecins sans Frontières.).
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http://dx.doi.org/10.1056/NEJMoa1312680DOI Listing
May 2014

First outbreak response using an oral cholera vaccine in Africa: vaccine coverage, acceptability and surveillance of adverse events, Guinea, 2012.

PLoS Negl Trop Dis 2013 17;7(10):e2465. Epub 2013 Oct 17.

Epicentre, Paris, France.

Background: Despite World Health Organization (WHO) prequalification of two safe and effective oral cholera vaccines (OCV), concerns about the acceptability, potential diversion of resources, cost and feasibility of implementing timely campaigns has discouraged their use. In 2012, the Ministry of Health of Guinea, with the support of Médecins Sans Frontières organized the first mass vaccination campaign using a two-dose OCV (Shanchol) as an additional control measure to respond to the on-going nationwide epidemic. Overall, 316,250 vaccines were delivered. Here, we present the results of vaccination coverage, acceptability and surveillance of adverse events.

Methodology/principal Findings: We performed a cross-sectional cluster survey and implemented adverse event surveillance. The study population included individuals older than 12 months, eligible for vaccination, and residing in the areas targeted for vaccination (Forécariah and Boffa, Guinea). Data sources were household interviews with verification by vaccination card and notifications of adverse events from surveillance at vaccination posts and health centres. In total 5,248 people were included in the survey, 3,993 in Boffa and 1,255 in Forécariah. Overall, 89.4% [95%CI:86.4-91.8%] and 87.7% [95%CI:84.2-90.6%] were vaccinated during the first round and 79.8% [95%CI:75.6-83.4%] and 82.9% [95%CI:76.6-87.7%] during the second round in Boffa and Forécariah respectively. The two dose vaccine coverage (including card and oral reporting) was 75.8% [95%CI: 71.2-75.9%] in Boffa and 75.9% [95%CI: 69.8-80.9%] in Forécariah respectively. Vaccination coverage was higher in children. The main reason for non-vaccination was absence. No severe adverse events were notified.

Conclusions/significance: The well-accepted mass vaccination campaign reached high coverage in a remote area with a mobile population. Although OCV should not be foreseen as the long-term solution for global cholera control, they should be integrated as an additional tool into the response.
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http://dx.doi.org/10.1371/journal.pntd.0002465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798604PMC
May 2014

A look back at an ongoing problem: Shigella dysenteriae type 1 epidemics in refugee settings in Central Africa (1993-1995).

PLoS One 2009 13;4(2):e4494. Epub 2009 Feb 13.

Epicentre, Paris, France.

Background: Shigella dysenteriae type 1 (Sd1) is a cause of major dysentery outbreaks, particularly among children and displaced populations in tropical countries. Although outbreaks continue, the characteristics of such outbreaks have rarely been documented. Here, we describe the Sd1 outbreaks occurring between 1993 and 1995 in 11 refugee settlements in Rwanda, Tanzania and Democratic Republic of the Congo (DRC). We also explored the links between the different types of the camps and the magnitude of the outbreaks.

Methodology/principal Findings: Number of cases of bloody diarrhea and deaths were collected on a weekly basis in 11 refugee camps, and analyzed retrospectively. Between November 1993 and February 1995, 181,921 cases of bloody diarrhea were reported. Attack rates ranged from 6.3% to 39.1% and case fatality ratios (CFRs) from 1.5% to 9.0% (available for 5 camps). The CFRs were higher in children under age 5. In Tanzania where the response was rapidly deployed, the mean attack rate was lower than in camps in the region of Goma without an immediate response (13.3% versus 32.1% respectively).

Conclusions/significance: This description, and the areas where data is missing, highlight both the importance of collecting data in future epidemics, difficulties in documenting outbreaks occurring in complex emergencies and most importantly, the need to assure that minimal requirements are met.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0004494PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636862PMC
March 2009

Treatment of severe malnutrition with 2-day intramuscular ceftriaxone vs 5-day amoxicillin.

Ann Trop Paediatr 2008 Mar;28(1):13-22

Epicentre, Paris, France.

Background: Systemic antibiotics are routinely prescribed for severe acute malnutrition (SAM). However, there is no consensus regarding the most suitable regimen. In a therapeutic feeding centre in Khartoum, Sudan, a randomised, unblinded, superiority-controlled trial was conducted, comparing once daily intramuscular injection with ceftriaxone for 2 days with oral amoxicillin twice daily for 5 days in children aged 6-59 months with SAM.

Methods: Commencing with the first measured weight gain (WG) following admission, the risk difference and 95% confidence interval (95% CI) for children with a WG > or = 10 g/kg/day were calculated over a 14-day period. The recovery rate and case fatality ratio (CFR) between the two groups were also calculated.

Results: In an intention-to-treat analysis of 458 children, 53.5% (123/230) in the amoxicillin group and 55.7% (127/228, difference 2.2%, 95% CI -6.9-11.3) in the ceftriaxone group had a WG > or = 10 g/kg/day during a 14-day period. Recovery rate was 70% (161/230) in the amoxicillin group and 74.6% (170/228) in the ceftriaxone group (p=0.27). CFR was 3.9% (9/230) and 3.1% (7/228), respectively (p=0.67). Most deaths occurred within the 1st 2 weeks of admission.

Conclusion: In the absence of severe complications, either ceftriaxone or amoxicillin is appropriate for malnourished children. However, in ambulatory programmes, especially where there are large numbers of admissions, ceftriaxone should facilitate the work of medical personnel.
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http://dx.doi.org/10.1179/146532808X270635DOI Listing
March 2008

Conflict and emerging infectious diseases.

Emerg Infect Dis 2007 Nov;13(11):1625-31

Disease Control in Humanitarian Emerfencies, Health Security and Environmental Cluster, World Health Organization, Geneva, Switzerland.

Detection and control of emerging infectious diseases in conflict situations are major challenges due to multiple risk factors known to enhance emergence and transmission of infectious diseases. These include inadequate surveillance and response systems, destroyed infrastructure, collapsed health systems and disruption of disease control programs, and infection control practices even more inadequate than those in resource-poor settings, as well as ongoing insecurity and poor coordination among humanitarian agencies. This article outlines factors that potentiate emergence and transmission of infectious diseases in conflict situations and highlights several priority actions for their containment and control.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375795PMC
http://dx.doi.org/10.3201/eid1311.061093DOI Listing
November 2007

Nifurtimox plus Eflornithine for late-stage sleeping sickness in Uganda: a case series.

PLoS Negl Trop Dis 2007 Nov 7;1(2):e64. Epub 2007 Nov 7.

Epicentre, Paris, France.

Background: We report efficacy and safety outcomes from a prospective case series of 31 late-stage T.b. gambiense sleeping sickness (Human African Trypanosomiasis, HAT) patients treated with a combination of nifurtimox and eflornithine (N+E) in Yumbe, northwest Uganda in 2002-2003, following on a previously reported terminated trial in nearby Omugo, in which 17 patients received the combination under the same conditions.

Methodology/principal Findings: Eligible sequential late-stage patients received 400 mg/Kg/day eflornithine (Ornidyl, Sanofi-Aventis) for seven days plus 15 mg/Kg/day (20 mg for children <15 years old) nifurtimox (Lampit, Bayer AG) for ten days. Efficacy (primary outcome) was monitored for 24 months post discharge. Clinical and laboratory adverse events (secondary outcome) were monitored during treatment. All 31 patients were discharged alive, but two died post-discharge of non-HAT and non-treatment causes, and one was lost to follow-up. Efficacy ranged from 90.3% to 100.0% according to analysis approach. Five patients experienced major adverse events during treatment, and neutropenia was common (9/31 patients).

Conclusions/significance: Combined with the previous group of 17 trial patients, this case series yields a group of 48 patients treated with N+E, among whom no deaths judged to be treatment- or HAT-related, no treatment terminations and no relapses have been noted, a very favourable outcome in the context of late-stage disease. N+E could be the most promising combination regimen available for sleeping sickness, and deserves further evaluation.
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http://dx.doi.org/10.1371/journal.pntd.0000064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2100371PMC
November 2007