Cost-of-illness of cholera to households and health facilities in rural Malawi

<div><p>Cholera remains an important public health problem in many low- and middle-income countries. Vaccination has been recommended as a possible intervention for the prevention and control of cholera. Evidence, especially data on disease burden, cost-of-illness, delivery costs and cost-effectiveness to support a wider use of vaccine is still weak. This study aims at estimating the cost-of-illness of cholera to households and health facilities in Machinga and Zomba Districts, Malawi. A cross-sectional study using retrospectively collected cost data was undertaken in this investigation. One hundred patients were purposefully selected for the assessment of the household cost-of-illness and four cholera treatment centres and one health facility were selected for the assessment conducted in health facilities. Data collected for the assessment in households included direct and indirect costs borne by cholera patients and their families while only direct costs were considered for the assessment conducted in health facilities. Whenever possible, descriptive and regression analysis were used to assess difference in mean costs between groups of patients. The average costs to patients’ households and health facilities for treating an episode of cholera amounted to US$65.6 and US$59.7 in 2016 for households and health facilities, respectively equivalent to international dollars (I$) 249.9 and 227.5 the same year. Costs incurred in treating a cholera episode were proportional to duration of hospital stay. Moreover, 52% of households used coping strategies to compensate for direct and indirect costs imposed by the disease. Both households and health facilities could avert significant treatment expenditures through a broader use of pre-emptive cholera vaccination. These findings have direct policy implications regarding priority investments for the prevention and control of cholera.</p></div

Selected characteristics of the study patients and their caregivers.

<p>Selected characteristics of the study patients and their caregivers.</p

Average treatment cost of cholera to the health centre in 2016 USandI and I.

<p>Average treatment cost of cholera to the health centre in 2016 US$and I$.</p

Mean cholera costs to the patient and his household in 2016 USandinI and in I.

<p>Mean cholera costs to the patient and his household in 2016 US$and in I$.</p

Distribution of coping strategies used by households to compensate for cholera direct and indirect costs.

<p>Distribution of coping strategies used by households to compensate for cholera direct and indirect costs.</p

Average treatment cost of cholera across groups of patients in 2016 USandI and I.

<p>Average treatment cost of cholera across groups of patients in 2016 US$and I$.</p

Multi-site cholera surveillance within the African Cholera Surveillance Network shows endemicity in Mozambique, 2011–2015

<div><p>Background</p><p>Mozambique suffers recurrent annual cholera outbreaks especially during the rainy season between October to March. The African Cholera Surveillance Network (Africhol) was implemented in Mozambique in 2011 to generate accurate detailed surveillance data to support appropriate interventions for cholera control and prevention in the country.</p><p>Methodology/Principal findings</p><p>Africhol was implemented in enhanced surveillance zones located in the provinces of Sofala (Beira), Zambézia (District Mocuba), and Cabo Delgado (Pemba City). Data were also analyzed from the three outbreak areas that experienced the greatest number of cases during the time period under observation (in the districts of Cuamba, Montepuez, and Nampula). Rectal swabs were collected from suspected cases for identification of <i>Vibrio cholerae</i>, as well as clinical, behavioral, and socio-demographic variables. We analyzed factors associated with confirmed, hospitalized, and fatal cholera using multivariate logistic regression models.</p><p>A total of 1,863 suspected cases and 23 deaths (case fatality ratio (CFR), 1.2%) were reported from October 2011 to December 2015. Among these suspected cases, 52.2% were tested of which 23.5% were positive for <i>Vibrio cholerae</i> O1 Ogawa. Risk factors independently associated with the occurrence of confirmed cholera were living in Nampula city district, the year 2014, human immunodeficiency virus infection, and the primary water source for drinking.</p><p>Conclusions/Significance</p><p>Cholera was endemic in Mozambique during the study period with a high CFR and identifiable risk factors. The study reinforces the importance of continued cholera surveillance, including a strong laboratory component. The results enhanced our understanding of the need to target priority areas and at-risk populations for interventions including oral cholera vaccine (OCV) use, and assess the impact of prevention and control strategies. Our data were instrumental in informing integrated prevention and control efforts during major cholera outbreaks in recent years.</p></div

Cumulated cholera attack rates and deaths per prefecture during the 2012 Guinean epidemic.

<p>Cumulated cholera attack rates and deaths per prefecture during the 2012 Guinean epidemic.</p

Cholera in Maritime Guinea between February and May 2012.

<p>The map illustrates the early propagation of the outbreak along the coast and the cumulated attack rate per sub-prefecture. Village positions are available on the Index Mundi website (<a href="http://www.indexmundi.com/zp/gv/" target="_blank">http://www.indexmundi.com/zp/gv/</a>).</p

(A) Maximum likelihood phylogenetic tree of the seventh pandemic lineage of <i>V. cholerae</i> based on the SNP differences across the whole core genome and including a strain isolated during the onset of the Guinean 2012 outbreak.

<p>The pre-seventh pandemic isolate M66 was used as an outgroup to root the tree. Blue, green and red branches represent waves 1, 2 and 3, respectively. Purple and sky blue clade lineages represent the Kenyan clade and two South Asian clades within the third wave, respectively. Scale is provided as the number of substitutions per variable site. (B) Greater resolution of wave 3 of the seventh pandemic, in which the Guinean strain clustered distinctly from the two South Asian clades and the dominant Kenyan clade. Guinean isolate G298 is represented by the square while each colored circle indicates a spatially different isolate (as shown in the key). Scale is provided as the number of substitutions per variable site.</p