The potential impact of case-area targeted interventions in response to cholera outbreaks: A modeling study

Background: Cholera prevention and control interventions targeted to neighbors of cholera cases (case-area targeted interventions [CATIs]), including improved water, sanitation, and hygiene, oral cholera vaccine (OCV), and prophylactic antibiotics, may be able to efficiently avert cholera cases and deaths while saving scarce resources during epidemics. Efforts to quickly target interventions to neighbors of cases have been made in recent outbreaks, but little empirical evidence related to the effectiveness, efficiency, or ideal design of this approach exists. Here, we aim to provide practical guidance on how CATIs might be used by exploring key determinants of intervention impact, including the mix of interventions, “ring” size, and timing, in simulated cholera epidemics fit to data from an urban cholera epidemic in Africa. Methods and findings: We developed a micro-simulation model and calibrated it to both the epidemic curve and the small-scale spatiotemporal clustering pattern of case households from a large 2011 cholera outbreak in N’Djamena, Chad (4,352 reported cases over 232 days), and explored the potential impact of CATIs in simulated epidemics. CATIs were implemented with realistic logistical delays after cases presented for care using different combinations of prophylactic antibiotics, OCV, and/or point-of-use water treatment (POUWT) starting at different points during the epidemics and targeting rings of various radii around incident case households. Our findings suggest that CATIs shorten the duration of epidemics and are more resource-efficient than mass campaigns. OCV was predicted to be the most effective single intervention, followed by POUWT and antibiotics. CATIs with OCV started early in an epidemic focusing on a 100-m radius around case households were estimated to shorten epidemics by 68% (IQR 62% to 72%), with an 81% (IQR 69% to 87%) reduction in cases compared to uncontrolled epidemics. These same targeted interventions with OCV led to a 44-fold (IQR 27 to 78) reduction in the number of people needed to target to avert a single case of cholera, compared to mass campaigns in high-cholera-risk neighborhoods. The optimal radius to target around incident case households differed by intervention type, with antibiotics having an optimal radius of 30 m to 45 m compared to 70 m to 100 m for OCV and POUWT. Adding POUWT or antibiotics to OCV provided only marginal impact and efficiency improvements. Starting CATIs early in an epidemic with OCV and POUWT targeting those within 100 m of an incident case household reduced epidemic durations by 70% (IQR 65% to 75%) and the number of cases by 82% (IQR 71% to 88%) compared to uncontrolled epidemics. CATIs used late in epidemics, even after the peak, were estimated to avert relatively few cases but substantially reduced the number of epidemic days (e.g., by 28% [IQR 15% to 45%] for OCV in a 100-m radius). While this study is based on a rigorous, data-driven approach, the relatively high uncertainty about the ways in which POUWT and antibiotic interventions reduce cholera risk, as well as the heterogeneity in outbreak dynamics from place to place, limits the precision and generalizability of our quantitative estimates. Conclusions: In this study, we found that CATIs using OCV, antibiotics, and water treatment interventions at an appropriate radius around cases could be an effective and efficient way to fight cholera epidemics. They can provide a complementary and efficient approach to mass intervention campaigns and may prove particularly useful during the initial phase of an outbreak, when there are few cases and few available resources, or in order to shorten the often protracted tails of cholera epidemics

Influence of initial soil moisture in a regional climate model study over West Africa - Part 1: Impact on the climate mean

International audienceThe impact of soil moisture initial conditions on the mean climate over West Africa was examined using the latest version of the regional climate model of the International Centre for Theoretical Physics (RegCM4) at a 25 km horizontal resolution. The soil moisture reanalysis of the European Centre for Medium-Range Weather Forecasts (ECMWF) reanalysis of the 20th century (ERA-20C) was used to initialize the control experiment, while its minimum and maximum values over the entire domain were used to establish the respective initial dry and wet soil moisture conditions (hereafter referred to as dry and wet experiments, respectively). For the respective control, wet and dry experiments, an ensemble of five runs from June to September was performed. In each experiment, we analyzed the two idealized simulations most sensitive to the dry and wet soil moisture initial conditions. The impact of soil moisture initial conditions on precipitation in West Africa is linear over the Central and West Sahel regions, where dry (wet) experiments lead to a rainfall decrease (increase). The strongest precipitation increase is found over the West Sahel for wet experiments, with a maximum change value of approximately 40 %, whereas the strongest precipitation decrease is found for dry experiments over the Central Sahel, with a peak change of approximately −4 %. The sensitivity of soil moisture initial conditions can persist for 3-4 months (90-120 d) depending on the region. However, the influence on precipitation is no longer than 1 month (between 15 and 30 d). The strongest temperature decrease is located over the Central and West Sahel, with a maximum change of approximately −1.5 °C in wet experiments, whereas the strongest temperature increase is found over the Guinea coast and Central Sahel for the dry experiments, with a maximum change of around 0.6 °C. A significant impact of soil moisture initial conditions on the surface energy fluxes is noted: in the wet (dry) experiments, a cooling (warming) of the surface temperature is associated with a decrease (increase) in sensible heat flux, an increase (decrease) in latent heat flux and a decrease (increase) in the boundary layer depth. Part 2 of this study (Koné et al., 2022) investigates the influence of soil moisture initial conditions on climate extremes

Influence of initial soil moisture in a regional climate model study over West Africa - Part 2: Impact on the climate extremes

International audienceThe influence of soil moisture initial conditions on the climate extreme indices over West Africa was investigated using the fourth generation of the International Centre for Theoretical Physics regional climate model (non-hydrostatic) coupled with version 4.5 of the Community Land Model (RegCM4-CLM4.5) at a 25 km spatial resolution. We initialized the control experiments with the reanalysis soil moisture data from the European Centre for Medium-Range Weather Forecasts (ECMWF) reanalysis of the 20th century (ERA-20C), while we initialized the dry and wet experiments with the maximum and minimum soil moisture values over the West Africa domain, respectively. For each experiment, an ensemble of five runs was performed for 5 years (2001-2005) with soil moisture initial conditions for the runs prescribed on 1 June and the simulations being performed over 4 months (122 d) from June to September. The performance of RegCM4-CLM4.5 with respect to simulating the 10 extreme rainfall and temperature indices used in this study is presented. The results are then discussed for the two idealized simulations that are most sensitive to the dry and wet soil moisture initial conditions in order to highlight the impacts beyond the limits of soil moisture internal forcing in the model. Over the Central Sahel, dry (wet) experiments lead to a decrease (increase) in precipitation extreme indices related to the number of events, but this was not seen for indices related to the intensity of the events. Soil moisture initial conditions unequally affect the daily minimum and maximum temperatures. The strongest impact is found on the maximum temperature: wet (dry) experiments decrease (increase) the maximum temperature over the whole region. Over the Central Sahel, wet (dry) experiments lead to a decrease (increase) in the maximum values of the minimum temperature

Influence of initial soil moisture in a Regional Climate Model study over West Africa. Part 2: Impact on the climate extremes

Abstract. The influence of the anomalies in initial soil moisture on the climate extreme over West Africa is investigated using the fourth generation of Regional Climate Model coupled to the version 4.5 of the Community Land Model (RegCM4-CLM4.5). We applied the initial soil moisture on June 1st for two summers June–July–August–September (JJAS) 2003 and JJAS 2004 (Resp. wet and dry year in the region of interest) with 25 km of spatial resolution. We initialized the control runs with the reanalysis soil moisture of the European Centre Meteorological Weather Forecast's reanalysis of the 20th century (ERA20C), while for the dry and wet experiments, we initialized the soil moisture respectively at the wilting points and field capacity. The impact on extreme precipitation indices of the initial soil moisture, especially over the central Sahel, is homogeneous, i.e. dry (wet) experiments tend to decrease (increase) precipitation extreme indices only for precipitation indices related to the number of precipitation events, not for those related to the intensity of precipitation events. Overall, the impact on temperature extremes of the anomalies in initial soil moisture is more significant compared to precipitation extremes. Initial soil moisture anomalies unequally affect daily minimum and maximum temperature. A stronger impact is found on maximum temperature than minimum temperature. Over the entire West African domain, wet (dry) experiments cause a decrease (increase) in maximum temperature. The strongest impacts on minimum temperature indices are found mainly in wet experiments, on the Sahara where we found the higher values of the maximum and minimum daily minimum temperature indices (resp. TNx and TNn). The performance of RegCM4-CLM4.5 in simulating the ten (10) extreme rainfall and temperature indices used in this study is also highlighted

Influence of initial soil moisture in a Regional Climate Model study over West Africa: Part 1: Impact on the climate mean

Abstract. The impact of the anomalies in initial soil moisture in later spring on the subsequent mean climate over West Africa is examined using the latest version of Regional Climate Model of the International Centre for Theoretical Physics (RegCM4). We performed this sensitivity studies over the West African domain, for June–July–August–September (JJAS) 2003 (wet year) and JJAS 2004 (a dry year) at the horizontal resolution of 25 km × 25 km. The reanalysis soil moisture of the European Centre Meteorological Weather Forecast's reanalysis of the 20th century (ERA20C) were used to initialize the control runs, whereas we initialized the soil moisture at the wilting points and field capacity respectively in dry and wet experiments. The impact of the anomalies in initial soil moisture on the precipitation in West Africa is homogeneous only over the central Sahel where dry (wet) experiments lead to rainfall decrease (increase). The strongest impact on precipitation in wet and dry experiments is found respectively over west and central Sahel with the peak of change about respectively 40 % and −8 %. The impact of the anomalies in initial soil moisture can persist for three or even four months, however the significance influence on precipitation, greater than 1 mm day−1, of the impact of the anomalies in initial soil moisture is much shorter, no longer than one month. The effect of soil moisture anomalies is mostly confined to the near-surface climate and in the upper troposphere. Overall, the impact of the anomalies in initial soil moisture is greater on temperature than on precipitation over most areas studied. The strongest homogeneous impacts of the anomalies in initial soil moisture on temperature is located over the central Sahel with the peak of change at −1.5 °C and 0.5 °C respectively in wet and dry experiments. The influence of initial the anomalies in initial soil moisture on the precipitation mechanism is also highlighted. We will investigate in the Part II of this study the influence of the anomalies in initial soil moisture on climate extremes

Comparison of the simulated evolution of epidemics with and without case-area targeted interventions.

<p>Upper panels in each pair of panels show the simulated evolution of the epidemics without intervention and with case-area targeted allocation of antibiotics, OCV, or POUWT within a 100-m radius starting at the epidemic peak. Lower panels in each pair of panels show the corresponding number of people targeted daily and the number of people protected by each intervention. Solid lines designate the median over all simulations, shaded areas the 2.5th and 97.5th percentiles. The red bars at the top of the panels mark the period during which interventions were applied. OCV, oral cholera vaccine; POUWT, point-of-use water treatment.</p

Intervention outcomes as a function of distance in case-area targeted allocations.

<p>The numbers of (A–C) averted cases, (D–F) targeted persons, and (G–I) targeted clusters predicted by the model for the 3 main intervention types with case-area targeted allocation and variable radius, starting at 3 different times. The error bars cover the range between the 25th and the 75th quantile over all simulations.</p

Reduction of epidemic duration with case-area targeted interventions.

<p>Reduction of epidemic duration predicted by the model for the 3 main intervention types with case-area targeted allocation in a 100-m radius starting at 3 different times. Whiskers mark the 2.5th and 97.5th percentiles. Negative numbers of days, such as visible for antibiotics, are due to stochastic effects that arise when an intervention alters the course of a particular epidemic without halting it and leads to a higher number of cases at a later point in time. OCV, oral cholera vaccine; POUWT, point-of-use water treatment.</p

Number of rings needed to target per day when implementing different case-area targeted interventions in a 100-m radius starting early, around the peak, and late in the epidemic (median (IQR)).

<p>Number of rings needed to target per day when implementing different case-area targeted interventions in a 100-m radius starting early, around the peak, and late in the epidemic (median (IQR)).</p

Calibrated model fit.

<p>(A) shows the distribution of daily incident cholera cases from uncontrolled epidemic simulations. The shaded areas represent the marginal interquartile range (dark blue) and the 2.5th and 97.5th percentiles (light blue) from 1,000 simulated epidemics with the true number of daily reported cases shown as red dots. Red ticks at the top represent the 3 times when interventions start. (B) shows the interquartile range (dark blue) and 2.5th and 97.5th posterior percentiles (light blue) of the relative risk (τ statistic) of the next case being within a specific distance from a case within 5 days of his/her symptom onset. Red dots and bars (95% confidence intervals) represent the computed τ from the data.</p