Volume 98, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



During 2014, Africa reported more than half of the global suspected cholera cases. Based on the data collected from seven countries in the African Cholera Surveillance Network (Africhol), we assessed the sensitivity, specificity, and positive and negative predictive values of clinical cholera case definitions, including that recommended by the World Health Organization (WHO) using culture confirmation as the gold standard. The study was designed to assess results in real-world field situations in settings with recent cholera outbreaks or endemicity. From June 2011 to July 2015, a total of 5,084 persons with suspected cholera were tested for in seven different countries of which 35.7% had culture confirmation. For all countries combined, the WHO case definition had a sensitivity = 92.7%, specificity = 8.1%, positive predictive value = 36.1%, and negative predictive value = 66.6%. Adding dehydration, vomiting, or rice water stools to the case definition could increase the specificity without a substantial decrease in sensitivity. Future studies could further refine our findings primarily by using more sensitive methods for cholera confirmation.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. Mengel MA, Delrieu I, Heyerdahl L, Gessner BD, 2014. Cholera outbreaks in Africa. Curr Top Microbiol Immunol 379: 117144.
    [Google Scholar]
  2. WHO, 2014. Weekly Epidemiological Record, Vol. 89, 345356. Available at: http://www.who.int/wer/2014/wer8931/en/. Accessed June 2, 2016.
  3. WHO, 2015. Weekly Epidemiological Record, Vol. 90, 517544. Available at: http://www.who.int/wer/2015/wer9040/en/. Accessed June 2, 2016.
  4. WHO, 2005. Weekly Epidemiological Record, Vol. 80, 261268. Available at: http://www.who.int/wer/2005/wer8031.pdf?ua=1.
  5. WHO, 2009. Weekly Epidemiological Record, Vol. 84, 309324. Available at: http://www.who.int/wer/2009/wer8431.pdf?ua=1.
  6. Gangarosa EJ, Mosley WH, 1974. Epidemiology and surveillance of cholera. Barua D, Burrows W, eds. Cholera. Philadelphia, PA: W.B. Saunders, 381403.
  7. WHO, 2016. Cholera. Available at: http://www.who.int/mediacentre/factsheets/fs107/en/. Accessed June 3, 2016.
  8. Kaper JB, Morris JG, Levine MM, 1995. Cholera. Clin Microbiol Rev 8: 4886.
    [Google Scholar]
  9. Azman AS, Rudolph KE, Cummings DAT, Lessler J, 2013. The incubation period of cholera: a systematic review. J Infect 66: 432438.
    [Google Scholar]
  10. Lucien MAB, Schaad N, Steenland MW, Mintz ED, Emmanuel R, Freeman N, Boncy J, Adrien P, Joseph GA, Katz MA, 2015. Identifying the most sensitive and specific sign and symptom combinations for cholera: results from an analysis of laboratory-based surveillance data from Haiti, 2012–2013. Am J Trop Med Hyg 92: 758764.
    [Google Scholar]
  11. Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA, 2006. Laboratory medicine in Africa: a barrier to effective health care. Clin Infect Dis 42: 377382.
    [Google Scholar]
  12. Debes AK, Ateudjieu J, Guenou E, Ebile W, Sonkoua IT, Njimbia AC, Steinwald P, Ram M, Sack DA, 2016. Clinical and environmental surveillance for Vibrio cholerae in resource constrained areas: application during a 1-year surveillance in the far north region of Cameroon. Am J Trop Med Hyg 94: 537543.
    [Google Scholar]
  13. Njanpop-Lafourcade B-M, Hugonnet S, Djogbe H, Kodjo A, N’douba AK, Taha MK, Stoeckel P, Gessner BD, 2013. Mobile microbiological laboratory support for evaluation of a meningitis epidemic in northern Benin. PLoS ONE 8: e68401.
    [Google Scholar]
  14. Sauvageot D et al., 2016. Cholera incidence and mortality in sub-Saharan African sites during multi-country surveillance. PLoS Negl Trop Dis 10: e0004679.
    [Google Scholar]
  15. Perilla MJ, Ajello G, Bopp C, Elliot J, Facklam R, Snapp JS, Popovic T, Wells J, Dowell SE, Centers for Disease Control and Prevention, 2003. Manual for the Laboratory Identification and Antimicrobial Susceptibility Testing of Bacterial Pathogens of Public Health Importance in the Developing World. Atlanta, GA: Centers for Disease Control and Prevention.
  16. Bryan ML, Jenkins SP, 2016. Multilevel modelling of country effects: a cautionary tale. Eur Sociol Rev 32: 322.
    [Google Scholar]
  17. WHO, 2008. Prevention and Control of Cholera Outbreaks: WHO Policy and Recommendations. Available at: http://www.who.int/cholera/technical/prevention/control/en/index1.html. Accessed June 3, 2016.
  18. WHO, 2009. Weekly Epidemiological Record, Vol. 84, 109116. Available at: http://www.who.int/wer/2009/wer8414/en/. Accessed June 3, 2016.
  19. Ahmed S, Bardhan PK, Iqbal A, Mazumder RN, Khan AI, Islam MS, Siddique AK, Cravioto A, 2011. The 2008 cholera epidemic in Zimbabwe: experience of the icddr,b team in the field. J Health Popul Nutr 29: 541546.
    [Google Scholar]
  20. Barzilay EJ, Schaad N, Magloire R, Mung KS, Boncy J, Dahourou GA, Mintz ED, Steenland MW, Vertefeuille JF, Tappero JW, 2013. Cholera surveillance during the Haiti epidemic—the first 2 years. N Engl J Med 368: 599609.
    [Google Scholar]
  21. WHO, 2010. Cholera in Haiti—Update 4. Available at: http://www.who.int/csr/don/2010_11_24/en/. Accessed June 3, 2016.
  22. Weil AA, Khan AI, Chowdhury F, LaRocque RC, Faruque ASG, Ryan ET, Calderwood SB, Qadri F, Harris JB, 2009. Clinical outcomes in household contacts of patients with cholera in Bangladesh. Clin Infect Dis 49: 14731479.
    [Google Scholar]
  23. Valcin C-L et al., 2013. Predictors of disease severity in patients admitted to a cholera treatment center in urban Haiti. Am J Trop Med Hyg 89: 625632.
    [Google Scholar]
  24. Kotloff KL et al., 2013. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet 382: 209222.
    [Google Scholar]
  25. Alam M et al., 2010. Diagnostic limitations to accurate diagnosis of cholera. J Clin Microbiol 48: 39183922.
    [Google Scholar]
  26. Page A-L, Alberti KP, Mondonge V, Rauzier J, Quilici M-L, Guerin PJ, 2012. Evaluation of a rapid test for the diagnosis of cholera in the absence of a gold standard. PLoS One 7: e37360.
    [Google Scholar]

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Supplemental Table

  • Received : 27 Jun 2016
  • Accepted : 20 Dec 2017
  • Published online : 26 Feb 2018
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