Estimating the gap between clinical cholera and true community infections: findings from an integrated surveillance study in an endemic region of Bangladesh

Our understanding of cholera transmission and burden largely rely on clinic-based surveillance, which can obscure trends, bias burden estimates and limit the impact of targeted cholera-prevention measures. Serologic surveillance provides a complementary approach to monitoring infections, though the link between serologically-derived infections and medically-attended disease – shaped by immunological, behavioral, and clinical factors – remains poorly understood. We unravel this cascade in a cholera-endemic Bangladeshi community by integrating clinic-based surveillance, healthcare seeking, and longitudinal serological data through statistical modeling. We found >50% of the study population had a V. cholerae O1 infection annually, and infection timing was not consistently correlated with reported cases. Four in 2,340 infections resulted in symptoms, only one of which was reported through the surveillance system. These results provide new insights into cholera transmission dynamics and burden in the epicenter of the 7(th) cholera pandemic and provide a framework to synthesize serological and clinical surveillance data.