Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria.

IF 15.8 1区 医学 Q1 Medicine PLoS Medicine Pub Date : 2024-05-10 eCollection Date: 2024-05-01 DOI:10.1371/journal.pmed.1004404
Jennifer OKeeffe, Lindsay Salem-Bango, Michael R Desjardins, Daniele Lantagne, Chiara Altare, Gurpreet Kaur, Thomas Heath, Kanaganathan Rangaiya, Patricia Oke-Oghene Obroh, Ahmadu Audu, Baptiste Lecuyot, Timothée Zoungrana, Emmanuel Emeka Ihemezue, Solomon Aye, Mustafa Sikder, Shannon Doocy, Qiulin Wang, Melody Xiao, Paul B Spiegel
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Abstract

Background: Cholera outbreaks are on the rise globally, with conflict-affected settings particularly at risk. Case-area targeted interventions (CATIs), a strategy whereby teams provide a package of interventions to case and neighboring households within a predefined "ring," are increasingly employed in cholera responses. However, evidence on their ability to attenuate incidence is limited.

Methods and findings: We conducted a prospective observational cohort study in 3 conflict-affected states in Nigeria in 2021. Enumerators within rapid response teams observed CATI implementation during a cholera outbreak and collected data on household demographics; existing water, sanitation, and hygiene (WASH) infrastructure; and CATI interventions. Descriptive statistics showed that CATIs were delivered to 46,864 case and neighbor households, with 80.0% of cases and 33.5% of neighbors receiving all intended supplies and activities, in a context with operational challenges of population density, supply stock outs, and security constraints. We then applied prospective Poisson space-time scan statistics (STSS) across 3 models for each state: (1) an unadjusted model with case and population data; (2) an environmentally adjusted model adjusting for distance to cholera treatment centers and existing WASH infrastructure (improved water source, improved latrine, and handwashing station); and (3) a fully adjusted model adjusting for environmental and CATI variables (supply of Aquatabs and soap, hygiene promotion, bedding and latrine disinfection activities, ring coverage, and response timeliness). We ran the STSS each day of our study period to evaluate the space-time dynamics of the cholera outbreaks. Compared to the unadjusted model, significant cholera clustering was attenuated in the environmentally adjusted model (from 572 to 18 clusters) but there was still risk of cholera transmission. Two states still yielded significant clusters (range 8-10 total clusters, relative risk of 2.2-5.5, 16.6-19.9 day duration, including 11.1-56.8 cholera cases). Cholera clustering was completely attenuated in the fully adjusted model, with no significant anomalous clusters across time and space. Associated measures including quantity, relative risk, significance, likelihood of recurrence, size, and duration of clusters reinforced the results. Key limitations include selection bias, remote data monitoring, and the lack of a control group.

Conclusions: CATIs were associated with significant reductions in cholera clustering in Northeast Nigeria despite operational challenges. Our results provide a strong justification for rapid implementation and scale-up CATIs in cholera-response, particularly in conflict settings where WASH access is often limited.

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大规模霍乱疫情期间的病例区定向干预:尼日利亚东北部的前瞻性队列研究。
背景:霍乱疫情在全球范围内呈上升趋势,受冲突影响地区的风险尤其大。病例区定向干预(CATIs)是一种策略,由团队在预先确定的 "圈 "内向病例家庭和邻近家庭提供一揽子干预措施,这种策略在霍乱应对措施中越来越多地被采用。然而,有关这些措施能否降低发病率的证据却很有限:2021 年,我们在尼日利亚 3 个受冲突影响的州开展了一项前瞻性观察队列研究。快速反应小组的调查员在霍乱爆发期间观察了 CATI 的实施情况,并收集了有关家庭人口统计、现有水、环境卫生和个人卫生(WASH)基础设施以及 CATI 干预措施的数据。描述性统计数字显示,CATI 共向 46864 个病例家庭和邻里家庭提供了服务,其中 80.0% 的病例家庭和 33.5% 的邻里家庭获得了所有预期的物资和活动,但在实际操作中却面临着人口密度大、物资短缺和安全限制等挑战。然后,我们在每个州的 3 个模型中应用了前瞻性泊松时空扫描统计(STSS):(1) 包含病例和人口数据的未调整模型;(2) 根据霍乱治疗中心和现有讲卫生运动基础设施(改良水源、改良厕所和洗手站)的距离进行调整的环境调整模型;(3) 根据环境和 CATI 变量(Aquatabs 和肥皂供应、卫生宣传、床上用品和厕所消毒活动、环覆盖率和响应及时性)进行调整的完全调整模型。我们在研究期间每天运行 STSS,以评估霍乱爆发的时空动态。与未经调整的模型相比,在环境调整模型中,显著的霍乱集群现象有所减少(从 572 个集群减少到 18 个),但仍存在霍乱传播的风险。有两个州仍有明显的集群(总集群范围为 8-10 个,相对风险为 2.2-5.5,持续时间为 16.6-19.9 天,包括 11.1-56.8 个霍乱病例)。在完全调整模型中,霍乱集群完全减弱,在时间和空间上都没有明显的异常集群。集群的数量、相对风险、显著性、复发可能性、规模和持续时间等相关指标都加强了这一结果。主要局限性包括选择偏差、远程数据监控和缺乏对照组:尽管在操作上存在挑战,但 CATI 与尼日利亚东北部霍乱集群的显著减少有关。我们的研究结果为在霍乱应对工作中快速实施和推广 CATI 提供了有力的依据,尤其是在讲卫生运动常常受到限制的冲突环境中。
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来源期刊
PLoS Medicine
PLoS Medicine MEDICINE, GENERAL & INTERNAL-
CiteScore
17.60
自引率
0.60%
发文量
227
审稿时长
4-8 weeks
期刊介绍: PLOS Medicine is a prominent platform for discussing and researching global health challenges. The journal covers a wide range of topics, including biomedical, environmental, social, and political factors affecting health. It prioritizes articles that contribute to clinical practice, health policy, or a better understanding of pathophysiology, ultimately aiming to improve health outcomes across different settings. The journal is unwavering in its commitment to uphold the highest ethical standards in medical publishing. This includes actively managing and disclosing any conflicts of interest related to reporting, reviewing, and publishing. PLOS Medicine promotes transparency in the entire review and publication process. The journal also encourages data sharing and encourages the reuse of published work. Additionally, authors retain copyright for their work, and the publication is made accessible through Open Access with no restrictions on availability and dissemination. PLOS Medicine takes measures to avoid conflicts of interest associated with advertising drugs and medical devices or engaging in the exclusive sale of reprints.
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