Improved water supply infrastructure to reduce acute diarrhoeal diseases and cholera in Uvira, Democratic Republic of the Congo: Results and lessons learned from a pragmatic trial

Abstract

Background Safely managed drinking water is critical to prevent diarrhoeal diseases, including cholera, but evidence on the effectiveness of piped water supply in reducing these diseases in low-income and complex emergency settings remains scarce. Methods We conducted a trial of water supply infrastructure improvements in Uvira (DRC). Our primary objective was to estimate the relationship between a composite index of water service quality and the monthly number of suspected cholera cases admitted to treatment facilities and, as a secondary analysis, the number of cases confirmed by rapid diagnostic tests. Other exposures included the quantity of supplied water and service continuity. We used Poisson generalised linear models with generalised estimating equations to estimate incidence rate ratios. Findings Associations between suspected cholera incidence and water service quality (RR 0·86, 95% CI 0·73–1·01), quantity (RR 0·80, 95% CI 0·62–1·02) and continuity (RR 0·81, 95% CI 0·77–0·86) were estimated. The magnitudes of the associations were similar between confirmed cholera incidence and water service quality (RR 0·84, 95% CI 0·73–0·97), quantity (RR 0·76, 95% CI 0·61–0·94) and continuity (RR 0·75, 95% CI 0·69–0·81). These results suggest that an additional 5 L/user/day or 1.2 hour per day of water production could reduce confirmed cholera by 24% (95% CI 6–39%) and 25% (95% CI 19–31%), respectively. Interpretation Ensuring a sufficient and continuous piped water supply may substantially reduce the burden of endemic cholera and diarrhoeal diseases but evaluating this rigorously is challenging. Pragmatic strategies are needed for public health research on complex interventions in protracted emergency settings. Trial registration The trial is registered in ClinicalTrials.gov ID NCT02928341. https://classic.clinicaltrials.gov/ct2/show/NCT02928341.

Spatiotemporal Modeling of Cholera, Uvira, Democratic Republic of the Congo, 2016−2020

“…Ethics approval was provided by the London School of Hygiene and Tropical Medicine (#10603-5) and the University of Kinshasa School of Public Health (#ESP/CE/173B/2022) as an amendment to the primary study for which the cholera case data was collected ( 9 ).…”

“…In Uvira, a city in eastern DRC affected by protracted conflict, population displacement, and flooding, cholera is endemic, and stable transmission is punctuated by seasonal outbreaks ( 8 ). Citywide interventions include an ongoing piped water supply program with household tap installation beginning in late 2019 ( 9 ) and mass vaccination in mid-2020 ( 10 ). Using an enhanced surveillance system with rapid diagnostic testing (RDT), we investigated the location, timing, and prediction of clusters to identify outbreaks earlier and trigger early response.…”