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      Use of Oral Cholera Vaccine and Knowledge, Attitudes, and Practices Regarding Safe Water, Sanitation and Hygiene in a Long-Standing Refugee Camp, Thailand, 2012-2014

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          Abstract

          Oral cholera vaccines (OCVs) are relatively new public health interventions, and limited data exist on the potential impact of OCV use on traditional cholera prevention and control measures—safe water, sanitation and hygiene (WaSH). To assess OCV acceptability and knowledge, attitudes, and practices (KAPs) regarding cholera and WaSH, we conducted cross-sectional surveys, 1 month before (baseline) and 3 and 12 months after (first and second follow-up) a preemptive OCV campaign in Maela, a long-standing refugee camp on the Thailand-Burma border. We randomly selected households for the surveys, and administered questionnaires to female heads of households. In total, 271 (77%), 187 (81%), and 199 (85%) households were included in the baseline, first and second follow-up surveys, respectively. Anticipated OCV acceptability was 97% at baseline, and 91% and 85% of household members were reported to have received 1 and 2 OCV doses at first follow-up. Compared with baseline, statistically significant differences (95% Wald confidence interval not overlapping zero) were noted at first and second follow-up among the proportions of respondents who correctly identified two or more means of cholera prevention (62% versus 78% and 80%), reported boiling or treating drinking water (19% versus 44% and 69%), and washing hands with soap (66% versus 77% and 85%); a significant difference was also observed in the proportion of households with soap available at handwashing areas (84% versus 90% and 95%), consistent with reported behaviors. No significant difference was noted in the proportion of households testing positive for Escherichia coli in stored household drinking water at second follow-up (39% versus 49% and 34%). Overall, we observed some positive, and no negative changes in cholera- and WaSH-related KAPs after an OCV campaign in Maela refugee camp. OCV campaigns may provide opportunities to reinforce beneficial WaSH-related KAPs for comprehensive cholera prevention and control.

          Author Summary

          Safe water, sanitation, and hygiene (WaSH) are the primary measures for cholera prevention and control. Since 2010, oral cholera vaccines (OCVs) have been recommended as an additional tool for endemic and epidemic cholera prevention and control. Given the relatively new use of OCVs in public health programs, there is limited information on the impact of OCV use on traditional WaSH activities, i.e., can they serve as complementary tools, or will OCV use have a negative impact on WaSH-related behaviors? This study reports the findings of knowledge, attitudes and practices (KAP) surveys conducted before and after a preventive OCV campaign (2013) in a long-standing refugee camp in Thailand, where frequent cholera outbreaks had occurred in recent years. The surveys demonstrated high acceptability of the OCV campaign and several modest improvements in cholera and WaSH KAPs among the camp population. OCV campaigns may be used as opportunities to reinforce cholera and WaSH-related messaging towards strengthening comprehensive cholera prevention and control.

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          Most cited references 34

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          The global burden of cholera.

          To estimate the global burden of cholera using population-based incidence data and reports. Countries with a recent history of cholera were classified as endemic or non-endemic, depending on whether they had reported cholera cases in at least three of the five most recent years. The percentages of the population in each country that lacked access to improved sanitation were used to compute the populations at risk for cholera, and incidence rates from published studies were applied to groups of countries to estimate the annual number of cholera cases in endemic countries. The estimates of cholera cases in non-endemic countries were based on the average numbers of cases reported from 2000 to 2008. Literature-based estimates of cholera case-fatality rates (CFRs) were used to compute the variance-weighted average cholera CFRs for estimating the number of cholera deaths. About 1.4 billion people are at risk for cholera in endemic countries. An estimated 2.8 million cholera cases occur annually in such countries (uncertainty range: 1.4-4.3) and an estimated 87,000 cholera cases occur in non-endemic countries. The incidence is estimated to be greatest in children less than 5 years of age. Every year about 91,000 people (uncertainty range: 28,000 to 142,000) die of cholera in endemic countries and 2500 people die of the disease in non-endemic countries. The global burden of cholera, as determined through a systematic review with clearly stated assumptions, is high. The findings of this study provide a contemporary basis for planning public health interventions to control cholera.
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            5 year efficacy of a bivalent killed whole-cell oral cholera vaccine in Kolkata, India: a cluster-randomised, double-blind, placebo-controlled trial.

            Efficacy and safety of a two-dose regimen of bivalent killed whole-cell oral cholera vaccine (Shantha Biotechnics, Hyderabad, India) to 3 years is established, but long-term efficacy is not. We aimed to assess protective efficacy up to 5 years in a slum area of Kolkata, India. In our double-blind, cluster-randomised, placebo-controlled trial, we assessed incidence of cholera in non-pregnant individuals older than 1 year residing in 3933 dwellings (clusters) in Kolkata, India. We randomly allocated participants, by dwelling, to receive two oral doses of modified killed bivalent whole-cell cholera vaccine or heat-killed Escherichia coli K12 placebo, 14 days apart. Randomisation was done by use of a computer-generated sequence in blocks of four. The primary endpoint was prevention of episodes of culture-confirmed Vibrio cholerae O1 diarrhoea severe enough for patients to seek treatment in a health-care facility. We identified culture-confirmed cholera cases among participants seeking treatment for diarrhoea at a study clinic or government hospital between 14 days and 1825 days after receipt of the second dose. We assessed vaccine protection in a per-protocol population of participants who had completely ingested two doses of assigned study treatment. 69 of 31 932 recipients of vaccine and 219 of 34 968 recipients of placebo developed cholera during 5 year follow-up (incidence 2·2 per 1000 in the vaccine group and 6·3 per 1000 in the placebo group). Cumulative protective efficacy of the vaccine at 5 years was 65% (95% CI 52-74; p<0·0001), and point estimates by year of follow-up suggested no evidence of decline in protective efficacy. Sustained protection for 5 years at the level we reported has not been noted previously with other oral cholera vaccines. Established long-term efficacy of this vaccine could assist policy makers formulate rational vaccination strategies to reduce overall cholera burden in endemic settings. Bill & Melinda Gates Foundation and the governments of South Korea and Sweden. Copyright © 2013 Elsevier Ltd. All rights reserved.
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              Use of Vibrio cholerae vaccine in an outbreak in Guinea.

              The use of vaccines to prevent and control cholera is currently under debate. Shanchol is one of the two oral cholera vaccines prequalified by the World Health Organization; however, its effectiveness under field conditions and the protection it confers in the first months after administration remain unknown. The main objective of this study was to estimate the short-term effectiveness of two doses of Shanchol used as a part of the integrated response to a cholera outbreak in Africa. We conducted a matched case-control study in Guinea between May 20 and October 19, 2012. Suspected cholera cases were confirmed by means of a rapid test, and controls were selected among neighbors of the same age and sex as the case patients. The odds of vaccination were compared between case patients and controls in bivariate and adjusted conditional logistic-regression models. Vaccine effectiveness was calculated as (1-odds ratio)×100. Between June 8 and October 19, 2012, we enrolled 40 case patients and 160 controls in the study for the primary analysis. After adjustment for potentially confounding variables, vaccination with two complete doses was associated with significant protection against cholera (effectiveness, 86.6%; 95% confidence interval, 56.7 to 95.8; P=0.001). In this study, Shanchol was effective when used in response to a cholera outbreak in Guinea. This study provides evidence supporting the addition of vaccination as part of the response to an outbreak. It also supports the ongoing efforts to establish a cholera vaccine stockpile for emergency use, which would enhance outbreak prevention and control strategies. (Funded by Médecins sans Frontières.).
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS Negl Trop Dis
                PLoS Negl Trop Dis
                plos
                plosntds
                PLoS Neglected Tropical Diseases
                Public Library of Science (San Francisco, CA USA )
                1935-2727
                1935-2735
                19 December 2016
                December 2016
                : 10
                : 12
                Affiliations
                [1 ]Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                [2 ]Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                [3 ]Thailand Ministry of Public Health – U.S. Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
                [4 ]Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                [5 ]Première Urgence-Aide Médicale Internationale, Mae Sot, Thailand
                University of California San Diego School of Medicine, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                • Conceptualization: HMS CRP KAW KD.

                • Data curation: HMS EN.

                • Formal analysis: HMS KAW EN.

                • Funding acquisition: CP PT KD.

                • Investigation: HMS EN EMT AF NW NRA.

                • Methodology: HMS CRP KAW KD.

                • Project administration: HMS CP EN NW NRA PT KD.

                • Resources: PT.

                • Supervision: HMS EN CP KD.

                • Visualization: HMS EN KAW.

                • Writing – original draft: HMS CRP KAW KD.

                • Writing – review & editing: EN EMT AF NW NRA PT.

                [¤a]

                Current address: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

                [¤b]

                Current address: Division of Global HIV/AIDS and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

                Article
                PNTD-D-16-01424
                10.1371/journal.pntd.0005210
                5167226
                27992609

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                Counts
                Figures: 1, Tables: 6, Pages: 17
                Product
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Award ID: OPP1058728
                Award Recipient :
                This work was funded by the Bill and Melinda Gates Foundation (OPP1058728; CRP and KD; www.gatesfoundation.org/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology and Life Sciences
                Immunology
                Vaccination and Immunization
                Vaccines
                Cholera Vaccines
                Medicine and Health Sciences
                Immunology
                Vaccination and Immunization
                Vaccines
                Cholera Vaccines
                Medicine and Health Sciences
                Public and Occupational Health
                Preventive Medicine
                Vaccination and Immunization
                Vaccines
                Cholera Vaccines
                Medicine and Health Sciences
                Infectious Diseases
                Bacterial Diseases
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                Ecology and Environmental Sciences
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                Public and Occupational Health
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                Custom metadata
                Data cannot be made publicly available due to ethical restrictions and sensitivities. Deidentified survey data will be made available on request to Première Urgence Internationale (formerly Première Urgence-Aide Médicale Internationale) at contact@ 123456premiere-urgence.org .

                Infectious disease & Microbiology

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