Cholera at the Crossroads: The Association Between Endemic Cholera and National Access to Improved Water Sources and Sanitation

Benjamin L. Nygren Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

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Anna J. Blackstock Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

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Eric D. Mintz Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

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We evaluated World Health Organization (WHO) national water and sanitation coverage levels and the infant mortality rate as predictors of endemic cholera in the 5-year period following water and sanitation coverage estimates using logistic regression, receiver operator characteristic curves, and different definitions of endemicity. Each was a significant predictors of endemic cholera at P < 0.001. Using a value of 250 for annual cases reported in 3 of 5 years, a national water access level of 71% has 65% sensitivity and 65% specificity in predicting endemic cholera, a sanitation access level of 39% has 63% sensitivity and 62% specificity, and an infant mortality rate of 65/1,000 has 67% sensitivity and 69% specificity. Our findings reveal the tradeoff between sensitivity and specificity for these predictors of endemic cholera and highlight the substantial uncertainty in the data. More accurate global surveillance data will enable more precise characterization of the benefits of improved water and sanitation.

Author Notes

* Address correspondence to Benjamin L. Nygren, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-C09, Atlanta, GA 30329. E-mail: bnygren@cdc.gov

Financial support: This work was supported in part by the United States Agency for International Development.

Authors' addresses: Benjamin L. Nygren, Anna J. Blackstock, and Eric D. Mintz, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: bnygren@cdc.gov, hyp9@cdc.gov, and emintz@cdc.gov.

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