Cargando…

Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes

BACKGROUND: Cholera epidemics continue to challenge disease control, particularly in fragile and conflict-affected states. Rapid detection and response to small cholera clusters is key for efficient control before an epidemic propagates. To understand the capacity for early response in fragile state...

Descripción completa

Detalles Bibliográficos
Autores principales: Ratnayake, Ruwan, Finger, Flavio, Edmunds, W. John, Checchi, Francesco
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737284/
https://www.ncbi.nlm.nih.gov/pubmed/33317544
http://dx.doi.org/10.1186/s12916-020-01865-7
_version_ 1783622916489871360
author Ratnayake, Ruwan
Finger, Flavio
Edmunds, W. John
Checchi, Francesco
author_facet Ratnayake, Ruwan
Finger, Flavio
Edmunds, W. John
Checchi, Francesco
author_sort Ratnayake, Ruwan
collection PubMed
description BACKGROUND: Cholera epidemics continue to challenge disease control, particularly in fragile and conflict-affected states. Rapid detection and response to small cholera clusters is key for efficient control before an epidemic propagates. To understand the capacity for early response in fragile states, we investigated delays in outbreak detection, investigation, response, and laboratory confirmation, and we estimated epidemic sizes. We assessed predictors of delays, and annual changes in response time. METHODS: We compiled a list of cholera outbreaks in fragile and conflict-affected states from 2008 to 2019. We searched for peer-reviewed articles and epidemiological reports. We evaluated delays from the dates of symptom onset of the primary case, and the earliest dates of outbreak detection, investigation, response, and confirmation. Information on how the outbreak was alerted was summarized. A branching process model was used to estimate epidemic size at each delay. Regression models were used to investigate the association between predictors and delays to response. RESULTS: Seventy-six outbreaks from 34 countries were included. Median delays spanned 1–2 weeks: from symptom onset of the primary case to presentation at the health facility (5 days, IQR 5–5), detection (5 days, IQR 5–6), investigation (7 days, IQR 5.8–13.3), response (10 days, IQR 7–18), and confirmation (11 days, IQR 7–16). In the model simulation, the median delay to response (10 days) with 3 seed cases led to a median epidemic size of 12 cases (upper range, 47) and 8% of outbreaks ≥ 20 cases (increasing to 32% with a 30-day delay to response). Increased outbreak size at detection (10 seed cases) and a 10-day median delay to response resulted in an epidemic size of 34 cases (upper range 67 cases) and < 1% of outbreaks < 20 cases. We estimated an annual global decrease in delay to response of 5.2% (95% CI 0.5–9.6, p = 0.03). Outbreaks signaled by immediate alerts were associated with a reduction in delay to response of 39.3% (95% CI 5.7–61.0, p = 0.03). CONCLUSIONS: From 2008 to 2019, median delays from symptom onset of the primary case to case presentation and to response were 5 days and 10 days, respectively. Our model simulations suggest that depending on the outbreak size (3 versus 10 seed cases), in 8 to 99% of scenarios, a 10-day delay to response would result in large clusters that would be difficult to contain. Improving the delay to response involves rethinking the integration at local levels of event-based detection, rapid diagnostic testing for cluster validation, and integrated alert, investigation, and response.
format Online
Article
Text
id pubmed-7737284
institution National Center for Biotechnology Information
language English
publishDate 2020
publisher BioMed Central
record_format MEDLINE/PubMed
spelling pubmed-77372842020-12-17 Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes Ratnayake, Ruwan Finger, Flavio Edmunds, W. John Checchi, Francesco BMC Med Research Article BACKGROUND: Cholera epidemics continue to challenge disease control, particularly in fragile and conflict-affected states. Rapid detection and response to small cholera clusters is key for efficient control before an epidemic propagates. To understand the capacity for early response in fragile states, we investigated delays in outbreak detection, investigation, response, and laboratory confirmation, and we estimated epidemic sizes. We assessed predictors of delays, and annual changes in response time. METHODS: We compiled a list of cholera outbreaks in fragile and conflict-affected states from 2008 to 2019. We searched for peer-reviewed articles and epidemiological reports. We evaluated delays from the dates of symptom onset of the primary case, and the earliest dates of outbreak detection, investigation, response, and confirmation. Information on how the outbreak was alerted was summarized. A branching process model was used to estimate epidemic size at each delay. Regression models were used to investigate the association between predictors and delays to response. RESULTS: Seventy-six outbreaks from 34 countries were included. Median delays spanned 1–2 weeks: from symptom onset of the primary case to presentation at the health facility (5 days, IQR 5–5), detection (5 days, IQR 5–6), investigation (7 days, IQR 5.8–13.3), response (10 days, IQR 7–18), and confirmation (11 days, IQR 7–16). In the model simulation, the median delay to response (10 days) with 3 seed cases led to a median epidemic size of 12 cases (upper range, 47) and 8% of outbreaks ≥ 20 cases (increasing to 32% with a 30-day delay to response). Increased outbreak size at detection (10 seed cases) and a 10-day median delay to response resulted in an epidemic size of 34 cases (upper range 67 cases) and < 1% of outbreaks < 20 cases. We estimated an annual global decrease in delay to response of 5.2% (95% CI 0.5–9.6, p = 0.03). Outbreaks signaled by immediate alerts were associated with a reduction in delay to response of 39.3% (95% CI 5.7–61.0, p = 0.03). CONCLUSIONS: From 2008 to 2019, median delays from symptom onset of the primary case to case presentation and to response were 5 days and 10 days, respectively. Our model simulations suggest that depending on the outbreak size (3 versus 10 seed cases), in 8 to 99% of scenarios, a 10-day delay to response would result in large clusters that would be difficult to contain. Improving the delay to response involves rethinking the integration at local levels of event-based detection, rapid diagnostic testing for cluster validation, and integrated alert, investigation, and response. BioMed Central 2020-12-15 /pmc/articles/PMC7737284/ /pubmed/33317544 http://dx.doi.org/10.1186/s12916-020-01865-7 Text en © The Author(s) 2020 Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research Article
Ratnayake, Ruwan
Finger, Flavio
Edmunds, W. John
Checchi, Francesco
Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes
title Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes
title_full Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes
title_fullStr Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes
title_full_unstemmed Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes
title_short Early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes
title_sort early detection of cholera epidemics to support control in fragile states: estimation of delays and potential epidemic sizes
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737284/
https://www.ncbi.nlm.nih.gov/pubmed/33317544
http://dx.doi.org/10.1186/s12916-020-01865-7
work_keys_str_mv AT ratnayakeruwan earlydetectionofcholeraepidemicstosupportcontrolinfragilestatesestimationofdelaysandpotentialepidemicsizes
AT fingerflavio earlydetectionofcholeraepidemicstosupportcontrolinfragilestatesestimationofdelaysandpotentialepidemicsizes
AT edmundswjohn earlydetectionofcholeraepidemicstosupportcontrolinfragilestatesestimationofdelaysandpotentialepidemicsizes
AT checchifrancesco earlydetectionofcholeraepidemicstosupportcontrolinfragilestatesestimationofdelaysandpotentialepidemicsizes