Background
Global cholera burden and sub-Saharan Africa as a hotspot
Professional versus community-reported burden of cholera
Methods
Study settings by country
SE-DRC: Katanga province, southeastern Democratic Republic of Congo
Western Kenya: Nyanza province
Zanzibar archipelago, Tanzania
Survey design and instrument
Ethics statement
Approach to analysis
Results
Sample characteristics
Identification, perceived seriousness, fatality and past experience of cholera
Category | SE-DRC, n = 360 | Western Kenya, n = 379 | Zanzibar, n = 356 | ||||||
---|---|---|---|---|---|---|---|---|---|
Overall | % | % | % | ||||||
Identification of illnessa*** | 96.4 | 75.2 | 88.2 | ||||||
Seriousnessb*** | 81.1 | 91.3 | 96.6 | ||||||
Expected fatal outcome without treatmentc*** | 99.7 | 49.9 | 77.5 | ||||||
Past household episodes*** | 44.4 | 22.4 | 15.5 | ||||||
Past personal episodes* | 8.3 | 11.6 | 5.3 | ||||||
Site comparison | Urban, % | Rural, % |
P value | Urban, % | Rural, % |
P value | Urban, % | Rural, % | |
P value | |||||||||
Identification of illnessa
|
93.9
|
98.9
|
0.020
| 72.6 | 77.8 | 0.285 |
95.5
|
80.8
|
<0.001
|
Seriousnessb
|
85.6
|
76.7
|
0.030
| 91.6 | 91.0 | 0.832 | 95.0 | 98.3 | 0.084 |
Expected fatal outcome without treatmentc
| 99.4 | 100.0 | 0.317 |
60.0
|
39.7
|
<0.001
|
84.4
|
70.6
|
0.002
|
Past household episodes |
52.2
|
36.7
|
0.004
|
27.4
|
17.5
|
0.044
|
6.7
|
24.3
|
<0.001
|
Past personal episodes | 7.7 | 8.9 | 0.703 | 13.2 | 10.1 | 0.423 |
2.8
|
7.9
|
0.035
|
Gender comparison | Female, % | Male, % |
P value | Female, % | Male, % |
P value | Female, % | Male, % | |
P value | |||||||||
Identification of illnessa
| 97.8 | 95.0 | 0.170 | 78.8 | 71.5 | 0.122 | 88.3 | 88.1 | >0.999 |
Seriousnessb
| 79.0 | 83.2 | 0.295 | 91.2 | 91.4 | 0.907 | 96.1 | 97.2 | 0.577 |
Expected fatal outcome without treatmentc
| 99.5 | 100.0 | 0.320 | 52.9 | 46.8 | 0.151 | 74.9 | 80.2 | 0.257 |
Past household episodes | 43.1 | 45.8 | 0.563 |
15.5
|
29.6
|
0.003
| 12.9 | 18.1 | 0.172 |
Past personal episodes | 7.8 | 8.9 | 0.680 |
8.3
|
15.1
|
0.053
| 3.4 | 7.3 | 0.104 |
Patterns of distress: priority symptoms and psychosocial impact
Category | SE-DRC, n = 360 | Western Kenya, n = 379 | Zanzibar, n = 356 | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Overall | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | |||||||||
Interference with work/daily activities*** |
96.9
|
1.64
|
98.7
|
2.19
|
96.9
|
2.35
| |||||||||
Loss of family income*** |
92.5
|
2.41
|
96.3
|
2.63
|
95.5
|
2.13
| |||||||||
Sadness, anxiety, worry*** |
97.8
|
2.70
|
98.2
|
1.84
|
97.5
|
1.89
| |||||||||
Site comparison | Urban | Rural | Urban | Rural | Urban | Rural | |||||||||
Total reported | Prominence | Total reported | Prominence |
P value | Total reported | Prominence | Total reported | Prominence |
P value | Total reported | Prominence | Total reported | Prominence |
P value | |
Costs (transport, food, drugs) | 87.8 | 1.40 | 94.4 | 1.42 | 0.575 |
97.9
|
1.51
|
87.3
|
1.28
|
<0.001
| 97.2 | 2.07 | 96.0 | 1.67 | 0.142 |
Disruption of health services | 68.9 | 0.96 | 71.7 | 0.84 | 0.229 | 55.3 | 0.57 | 51.9 | 0.58 | 0.627 |
48.0
|
0.54
|
88.1
|
0.94
|
<0.001
|
Interference with social relationships |
67.2
|
1.12
|
86.7
|
1.56
|
<0.001
| 84.2 | 1.35 | 78.8 | 1.33 | 0.379 |
65.4
|
0.82
|
74.6
|
1.28
|
<0.001
|
Loss of family income | 91.1 | 2.57 | 93.9 | 2.25 | 0.174 |
97.9
|
2.94
|
94.7
|
2.31
|
<0.001
| 98.3 | 2.11 | 92.7 | 2.16 | 0.463 |
Sadness, anxiety, worry |
97.8
|
2.43
|
98.3
|
2.96
|
<0.001
| 100.0 | 1.90 | 96.3 | 1.78 | 0.064 |
100.0
|
2.06
|
94.9
|
1.72
|
<0.001
|
Gender comparison | Female | Male |
P value | Female | Male |
P value | Female | Male |
P value | ||||||
Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | ||||
Disruption of health services | 69.6 | 0.88 | 70.9 | 0.92 | 0.754 |
46.9
|
0.47
|
60.5
|
0.69
|
0.004
| 73.2 | 0.78 | 62.7 | 0.69 | 0.051 |
Interference with work/daily activities |
95.0
|
1.46
|
98.9
|
1.82
|
0.005
| 98.5 | 2.07 | 98.9 | 2.32 | 0.085 | 95.5 | 2.36 | 97.2 | 2.33 | 0.704 |
Loss of family income | 94.5 | 2.55 | 90.5 | 2.27 | 0.112 | 96.4 | 2.74 | 96.2 | 2.51 | 0.178 |
93.9
|
1.96
|
97.7
|
2.31
|
0.007
|
Perceived causes
Category | SE-DRC, n = 360 | Western Kenya, n = 379 | Zanzibar, n = 356 | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Overall | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | |||||||||
Dirty environment*** |
93.3
|
1.83
|
96.3
|
1.97
|
97.8
|
2.99
| |||||||||
Drinking contaminated water*** |
94.7
|
2.68
|
95.5
|
2.21
|
95.2
|
1.65
| |||||||||
Eating unprotected/spoiled food*** |
94.7
|
1.94
| 93.1 | 1.75 | 94.9 | 1.44 | |||||||||
Flies* | 95.3 | 1.44 | 96.0 | 1.30 |
96.9
|
1.60
| |||||||||
Lack of latrinesa*** | 93.3 | 1.72 |
95.8
|
1.79
| NA | NA | |||||||||
Site comparison | Urban | Rural |
P value | Urban | Rural |
P value | Urban | Rural |
P value | ||||||
Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | ||||
Contact with contaminated water | 84.4 | 1.17 | 89.4 | 1.12 | 0.657 | 55.8 | 0.64 | 63.0 | 0.75 | 0.115 |
85.5
|
1.07
|
91.0
|
1.58
|
<0.001
|
Dirty environment | 91.7 | 1.83 | 95.0 | 1.82 | 0.631 |
97.9
|
2.29
|
94.7
|
1.63
|
<0.001
|
99.4
|
3.68
|
96.0
|
2.30
|
<0.001
|
Drinking contaminated water |
93.3
|
2.34
|
96.1
|
3.02
|
<0.001
| 97.4 | 2.18 | 93.7 | 2.23 | 0.778 | 96.1 | 1.65 | 94.4 | 1.66 | 0.384 |
Eating forbidden food | 20.6 | 0.23 | 13.3 | 0.15 | 0.094 | 11.6 | 0.12 | 14.8 | 0.15 | 0.365 |
27.4
|
0.27
|
54.8
|
0.48
|
<0.001
|
Eating soil |
53.9
|
0.65
|
41.7
|
0.45
|
0.006
| 60.0 | 0.60 | 52.4 | 0.52 | 0.136 |
36.9
|
0.37
|
48.6
|
0.49
|
0.023
|
Eating unprotected/spoiled food | 92.8 | 1.89 | 96.7 | 1.99 | 0.100 | 95.3 | 1.75 | 91.0 | 1.74 | 0.432 |
95.5
|
1.60
|
94.4
|
1.27
|
<0.001
|
Flies | 93.3 | 1.37 | 97.2 | 1.52 | 0.236 |
96.3
|
1.35
|
95.8
|
1.25
|
0.004
| 99.4 | 1.62 | 94.4 | 1.58 | 0.163 |
God’s will | 40.0 | 0.56 | 42.2 | 0.55 | 0.668 | 8.9 | 0.09 | 7.4 | 0.07 | 0.586 |
93.3
|
1.22
|
86.4
|
1.83
|
0.001
|
Malaria | 26.1 | 0.30 | 20.0 | 0.21 | 0.115 | 19.5 | 0.21 | 24.9 | 0.25 | 0.243 |
15.1
|
0.15
|
48.0
|
0.49
|
<0.001
|
Witchcraft |
47.8
|
0.64
|
69.4
|
0.86
|
<0.001
| 9.5 | 0.09 | 11.6 | 0.12 | 0.494 |
20.7
|
0.21
|
45.8
|
0.50
|
<0.001
|
Worms | 36.1 | 0.39 | 36.7 | 0.39 | 0.976 |
23.2
|
0.24
|
39.7
|
0.40
|
0.001
|
13.4
|
0.13
|
46.9
|
0.47
|
<0.001
|
Cannot say | 4.4 | 0.11 | 3.9 | 0.14 | 0.638 |
2.1
|
0.42
|
11.6
|
0.77
|
0.005
|
1.1
|
0.02
|
13.6
|
0.27
|
<0.001
|
Gender comparison | Female | Male |
P value | Female | Male |
P value | Female | Male |
P value | ||||||
Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | ||||
Dirty environment | 92.3 | 1.77 | 94.4 | 1.89 | 0.251 |
96.9
|
1.84
|
95.7
|
2.10
|
0.043
| 97.8 | 2.91 | 97.7 | 3.07 | 0.334 |
Eating soil | 51.9 | 0.61 | 43.6 | 0.49 | 0.092 |
45.4
|
0.45
|
67.6
|
0.68
|
<0.001
| 43.6 | 0.44 | 41.8 | 0.42 | 0.772 |
Cannot say | 5.0 | 0.15 | 3.4 | 0.10 | 0.620 | 7.7 | 0.65 | 5.9 | 0.54 | 0.476 |
11.2
|
0.22
|
3.4
|
0.07
|
0.005
|
Knowledge of prevention and priority of hygiene and sanitation
Category | SE-DRC, n = 360 | Western Kenya, n = 379 | Zanzibar, n = 354 | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Overall | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | |||||||||
Health education | 92.5 | 1.75 |
98.9
|
1.89
|
95.5
|
1.90
| |||||||||
Safe disposal of garbage*** | 95.0 | 1.79 | 97.9 | 1.61 |
98.6
|
2.09
| |||||||||
Safe disposal of stool*** | 93.9 | 1.53 |
97.9
|
1.81
|
98.3
|
2.09
| |||||||||
Safe food*** |
95.3
|
1.92
| 98.4 | 1.67 | 97.5 | 1.66 | |||||||||
Safe water*** |
93.3
|
2.06
|
98.2
|
1.93
| 96.9 | 1.74 | |||||||||
Vaccines*** |
87.2
|
2.00
| 87.9 | 1.15 | 86.2 | 1.20 | |||||||||
Site comparison | Urban | Rural | Urban | Rural | Urban | Rural | |||||||||
Total reported | Prominence | Total reported | Prominence |
P value | Total reported | Prominence | Total reported | Prominence |
P value | Total reported | Prominence | Total reported | Prominence |
P value | |
Health education | 90.0 | 1.80 | 95.0 | 1.71 | 0.371 |
98.9
|
2.27
|
98.9
|
1.51
|
<0.001
| 96.6 | 1.93 | 94.3 | 1.88 | 0.581 |
Preventive drugs | 59.4 | 0.87 | 65.0 | 1.04 | 0.331 |
86.3
|
1.05
|
91.5
|
1.20
|
0.049
|
83.7
|
1.01
|
88.6
|
1.18
|
0.040
|
Protection from supernatural influencea
|
10.6
|
0.13
|
5.0
|
0.05
|
0.047
|
7.4
|
0.09
|
21.7
|
0.22
|
<0.001
| NA | NA | NA | NA | NA |
Safe disposal of garbage | 93.9 | 1.71 | 96.1 | 1.87 | 0.154 | 98.4 | 1.53 | 97.4 | 1.69 | 0.257 |
99.4
|
2.51
|
97.7
|
1.66
|
<0.001
|
Safe disposal of stool | 91.7 | 1.53 | 96.1 | 1.54 | 0.911 |
97.4
|
1.66
|
98.4
|
1.96
|
0.026
| 99.4 | 1.96 | 97.2 | 2.21 | 0.301 |
Safe food | 94.4 | 1.86 | 96.1 | 1.98 | 0.298 |
98.9
|
1.76
|
97.9
|
1.58
|
0.002
|
98.3
|
1.78
|
96.6
|
1.53
|
0.001
|
Gender comparison | Female | Male | Female | Male | Female | Male | |||||||||
Total reported | Prominence | Total reported | Prominence |
P value | Total reported | Prominence | Total reported | Prominence |
P value | Total reported | Prominence | Total reported | Prominence |
P value | |
Health education | 91.7 | 1.66 | 93.3 | 1.84 | 0.361 | 98.5 | 1.87 | 99.5 | 1.92 | 0.571 |
95.5
|
1.72
|
95.4
|
2.10
|
0.014
|
Protection from supernatural influencea
|
5.0
|
0.05
|
10.6
|
0.13
|
0.044
| 13.4 | 0.14 | 15.7 | 0.17 | 0.533 | NA | NA | NA | NA | NA |
Safe disposal of garbage | 95.6 | 1.78 | 94.4 | 1.79 | 0.500 |
97.4
|
1.52
|
98.4
|
1.70
|
0.026
| 98.9 | 2.13 | 98.3 | 2.05 | 0.906 |
Safe food | 94.5 | 1.98 | 96.1 | 1.86 | 0.206 | 98.5 | 1.69 | 98.4 | 1.65 | 0.888 |
98.3
|
1.78
|
96.6
|
1.53
|
0.013
|
Safe water | 92.3 | 2.15 | 94.4 | 1.98 | 0.159 |
98.5
|
2.04
|
97.8
|
1.82
|
0.019
| 97.2 | 1.77 | 96.6 | 1.71 | 0.926 |
Help-seeking behavior
Category | SE-DRC, n = 360 | Western Kenya, n = 379 | Zanzibar, n = 356 | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Overall | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | |||||||||
Drinking water/liquids*** |
55.6
|
0.86
|
89.4
|
2.00
|
69.1
|
1.32
| |||||||||
Herbal treatment*** | 50.3 | 0.84 | 33.2 | 0.62 |
66.3
|
1.79
| |||||||||
ORS*** |
92.8
|
3.26
|
87.1
|
2.20
|
66.3
|
1.45
| |||||||||
Self-administered drugs*** |
56.1
|
1.19
|
73.9
|
1.89
| 58.4 | 1.30 | |||||||||
Site comparison | Urban | Rural |
P value | Urban | Rural |
P value | Urban | Rural |
P value | ||||||
Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | ||||
Doing nothing at home | 5.6 | 0.09 | 10.6 | 0.24 | 0.109 |
0.5
|
0.03
|
5.3
|
0.12
|
0.020
|
27.9
|
1.25
|
19.8
|
0.53
|
0.005
|
Drinking water/liquids |
66.7
|
1.07
|
44.4
|
0.64
|
<0.001
| 87.9 | 1.93 | 91.0 | 2.07 | 0.493 |
68.7
|
1.58
|
69.5
|
1.05
|
0.006
|
Herbal treatment | 50.0 | 0.79 | 50.6 | 0.89 | 0.912 | 30.0 | 0.61 | 36.5 | 0.63 | 0.292 |
49.7
|
1.29
|
83.1
|
2.31
|
<0.001
|
Prayers | 44.4 | 0.80 | 50.6 | 0.74 | 0.497 |
51.1
|
0.68
|
32.3
|
0.37
|
<0.001
| 55.9 | 0.74 | 47.5 | 0.73 | 0.229 |
Self-administered drugs |
48.3
|
1.03
|
63.9
|
1.36
|
0.006
| 76.8 | 1.95 | 70.9 | 1.83 | 0.251 |
44.7
|
1.03
|
72.3
|
1.57
|
<0.001
|
Gender comparison | Female | Male |
P value | Female | Male |
P value | Female | Male |
P value | ||||||
Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | ||||
Alcoholic drinka
|
4.4
|
0.05
|
11.2
|
0.12
|
0.019
|
4.1
|
0.06
|
10.8
|
0.14
|
0.014
| NA | NA | NA | NA | NA |
Herbal treatment | 47.0 | 0.78 | 53.6 | 0.91 | 0.147 |
25.8
|
0.42
|
41.1
|
0.83
|
0.001
| 70.9 | 1.92 | 61.6 | 1.67 | 0.149 |
ORS | 91.7 | 3.27 | 93.9 | 3.26 | 0.790 |
90.2
|
2.38
|
83.8
|
2.01
|
0.017
| 65.4 | 1.36 | 67.2 | 1.53 | 0.492 |
Self-administered drugs |
50.3
|
1.07
|
62.0
|
1.32
|
0.023
| 69.6 | 1.87 | 78.4 | 1.91 | 0.585 | 61.5 | 1.35 | 55.4 | 1.25 | 0.363 |
Category | SE-DRC, n = 360 | Western Kenya, n = 379 | Zanzibar, n = 356 | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Overall | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | |||||||||
Faith healers |
19.4
|
0.31
| 18.5 | 0.23 | 14.9 | 0.18 | |||||||||
Healthcare facility |
100.0
|
4.79
|
100.0
|
4.76
|
100.0
|
4.64
| |||||||||
Informal help*** | 13.6 | 0.18 |
54.6
|
0.72
|
55.9
|
0.86
| |||||||||
Pharmacy/OTC*** |
19.4
|
0.20
|
59.1
|
0.70
|
34.0
|
0.36
| |||||||||
Site comparison | Urban | Rural |
P value | Urban | Rural |
P value | Urban | Rural |
P value | ||||||
Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | ||||
Healthcare facility |
100.0
|
4.69
|
100.0
|
4.90
|
0.001
|
100.0
|
4.87
|
99.5
|
4.65
|
0.005
|
100.0
|
4.87
|
100.0
|
4.41
|
<0.001
|
Informal help | 15.6 | 0.22 | 11.7 | 0.13 | 0.263 |
44.2
|
0.54
|
65.1
|
0.90
|
<0.001
|
38.5
|
0.52
|
73.4
|
1.21
|
<0.001
|
Pharmacy/OTC | 20.6 | 0.22 | 18.3 | 0.18 | 0.546 | 55.3 | 0.61 | 63.0 | 0.79 | 0.072 |
27.4
|
0.27
|
40.7
|
0.44
|
0.007
|
Traditional healers | 9.4 | 0.14 | 4.4 | 0.09 | 0.075 | 12.1 | 0.16 | 17.5 | 0.19 | 0.187 |
3.9
|
0.04
|
9.6
|
0.12
|
0.031
|
Gender comparison | Female | Male |
P value | Female | Male |
P value | Female | Male |
P value | ||||||
Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | Total reported | Prominence | ||||
Healthcare facility | 100.0 | 4.77 | 100.0 | 4.82 | 0.976 | 100.0 | 4.79 | 100.0 | 4.72 | 0.475 |
100.0
|
4.77
|
100.0
|
4.51
|
0.013
|
Informal help | 10.5 | 0.12 | 16.8 | 0.23 | 0.078 |
49.5
|
0.62
|
60.0
|
0.83
|
0.026
|
50.8
|
0.69
|
61.0
|
1.03
|
0.014
|
Traditional healers | 5.0 | 0.08 | 8.9 | 0.15 | 0.159 |
10.3
|
0.12
|
19.5
|
0.22
|
0.014
| 7.8 | 0.08 | 5.6 | 0.07 | 0.418 |
Vulnerability to the illness
Category | SE-DRC, n = 360 | Western Kenya, n = 379 | Zanzibar, n = 356 |
---|---|---|---|
Sex | |||
No differentiation | 90.6 | 63.6 | 87.1 |
Women more vulnerable | 6.9 | 24.5 | 10.4 |
Men more vulnerable | 2.5 | 11.9 | 2.5 |
Age | |||
No differentiation | 84.4 | 26.9 | 79.5 |
Adults more vulnerable | 8.1 | 22.4 | 8.1 |
Children more vulnerable | 7.5 | 50.7 | 12.4 |
Class | |||
No differentiation | 86.3 | 44.9 | 74.4 |
Rich more vulnerable | 0.6 | 2.9 | 0.0 |
Poor more vulnerable | 13.1 | 52.2 | 25.6 |