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Background In October 2010, Haiti was struck by a large-scale cholera epidemic. The Haitian government, UNICEF and other international partners launched an unprecedented nationwide alert-response strategy in July 2013. Coordinated NGOs recruited local rapid response mobile teams to conduct case-area targeted interventions (CATIs), including education sessions, household decontamination by chlorine spraying, and distribution of chlorine tablets. An innovative red - orange - green alert system was also established to monitor the epidemic at the communal scale on a weekly basis. Our study aimed to describe and evaluate the exhaustiveness, intensity and quality of the CATIs in response to cholera alerts in Haiti between July 2013 and June 2017. Methodology/principal findings We analyzed the response to 7,856 weekly cholera alerts using routine surveillance data and severity criteria, which was based on the details of 31,306 notified CATIs. The odds of CATI response during the same week (exhaustiveness) and the number of complete CATIs in responded alerts (intensity and quality) were estimated using multivariate generalized linear mixed models and several covariates. CATIs were carried out significantly more often in response to red alerts (adjusted odds ratio (aOR) [95%-confidence interval, 95%-CI], 2.52 [2.22–2.87]) compared with orange alerts. Significantly more complete CATIs were carried out in response to red alerts compared with orange alerts (adjusted incidence ratio (aIR), 1.85 [1.73–1.99]). Over the course of the eight-semester study, we observed a significant improvement in the exhaustiveness (aOR, 1.43 [1.38–1.48] per semester) as well as the intensity and quality (aIR, 1.23 [1.2–1.25] per semester) of CATI responses, independently of funds available for the strategy. The odds of launching a CATI response significantly decreased with increased rainfall (aOR, 0.99 [0.97–1] per each accumulated cm). Response interventions were significantly heterogeneous between NGOs, communes and departments. Conclusions/significance The implementation of a nationwide case-area targeted rapid response strategy to control cholera in Haiti was feasible albeit with certain obstacles. Such feedback from the field and ongoing impact studies will be very informative for actors and international donors involved in cholera control and elimination in Haiti and in other affected countries.

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BackgroundSince 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 FindingsIn 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/SignificanceTo 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.

The ongoing Ebola outbreak in the eastern Democratic Republic of the Congo is facing unprecedented levels of insecurity and violence. We evaluate the likely impact in terms of added transmissibility and cases of major security incidents in the Butembo coordination hub. We also show that despite this additional burden, an adapted response strategy involving enlarged ring vaccination around clusters of cases and enhanced community engagement managed to bring this main hotspot under control.

During 2004–2014, the Democratic Republic of the Congo (DRC) declared 54% of plague cases worldwide. Using national data, we characterized the epidemiology of human plague in DRC for this period. All 4,630 suspected human plague cases and 349 deaths recorded in DRC came from Orientale Province. Pneumonic plague cases (8.8% of total) occurred during 2 major outbreaks in mining camps in the equatorial forest, and some limited outbreaks occurred in the Ituri highlands. Epidemics originated in 5 health zones clustered in Ituri, where sporadic bubonic cases were recorded throughout every year. Classification and regression tree characterized this cluster by the dominance of ecosystem 40 (mountain tropical climate). In conclusion, a small, stable, endemic focus of plague in the highlands of the Ituri tropical region persisted, acting as a source of outbreaks in DRC.

C holera is an acute life-threatening diarrheal disease responsible for ≈4.3 million cases and 142,000 deaths annually worldwide (1). Excluding epidemic peaks in Haiti and Yemen (2,3), most cases of cholera originate from sub-Saharan Africa, predominantly the African Great Lakes Region (AGLR); specifically, the countries of the Lake Tanganyika basin (4). Many recurrent cholera outbreaks in the Democratic Republic of the Congo (DRC), Tanzania, Burundi, and Zambia have been linked to a common hotspot area around the Lake Tanganyika basin (5-8).By the end of 2018, the World Health Organization had noted a steady decline in cholera cases throughout the world, including the AGLR (9). Continuous genomic surveillance of circulating Vibrio cholerae bacteria strains is required to understand the transmission dynamics and genetic evolution of V. cholerae and potentially to guide prevention and response interventions to continue the trend toward decreasing case numbers, in line with the global cholera roadmap to 2030 (10). One lineage, seventh pandemic V. cholerae O1 El Tor (7PET), is responsible for the current pandemic, which began in 1961 (11); Africa was hit by 7PET in 1970 (11). During 1970-2014, >11 different 7PET sublineages were introduced from South Asia into Africa, and sublineage AFR10 (previously T10) replaced AFR5 (previously T5) in the AGLR in the late 1990s (11). Sublineage AFR13 (previously T13) was identified in East Africa (Tanzania, Uganda, Kenya) and Zimbabwe (12). We tracked the 7PET populations circulating in the Lake Tanganyika basin by studying recent V. cholerae O1 isolates collected in the region by conventional bacteriology and genomics and placing these genomes in a broader phylogenetic context to elucidate their evolutionary history. The StudyWe analyzed 96 V. cholerae O1 isolates collected during 2015-2020 in DRC (86 clinical isolates, including 39 collected in 2018-2020) and Tanzania (10 environmental isolates from fish and lake water) (Appendix 1, https://wwwnc.cdc.gov/EID/article/29/1/22-0641-App1.pdf; Appendix 2 Table 1, https://wwwnc. cdc.gov/EID/article/29/1/22-0641-App2.xlsx). We subjected the isolates to antimicrobial susceptibility testing, whole-genome sequencing, genomic characterization, and phylogenetic analyses, as previously Genomic Microevolution ofVibrio cholerae O1,

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