Improvements in malaria surveillance through the electronic Integrated Disease Surveillance and Response (eIDSR) system in mainland Tanzania, 2013-2021.

BACKGROUND: Tanzania has made remarkable progress in reducing malaria burden and aims to transition from malaria control to sub-national elimination. In 2013, electronic weekly and monthly reporting platforms using the District Health Information System 2 (DHIS2) were introduced. Weekly reporting was implemented through the mobile phone-based Integrated Disease Surveillance and Response (eIDSR) platform and progressively scaled-up from 67 to 7471 (100%) public and private health facilities between 2013 and 2020. This study describes the roll-out and large-scale implementation of eIDSR and compares the consistency between weekly eIDSR and monthly DHIS2 malaria indicator data reporting, including an assessment of its usefulness for malaria outbreak detection and case-based surveillance (CBS) in low transmission areas. METHODS: The indicators included in the analysis were number of patients tested for malaria, number of confirmed malaria cases, and clinical cases (treated presumptively for malaria). The analysis described the time trends of reporting, testing, test positivity, and malaria cases between 2013 and 2021. For both weekly eIDSR and monthly DHIS2 data, comparisons of annual reporting completeness, malaria cases and annualized incidence were performed for 2020 and 2021; additionally, comparisons were stratified by malaria epidemiological strata (parasite prevalence: very low < 1%, low 1 ≤ 5%, moderate 5 ≤ 30%, and high > 30%). RESULTS: Weekly eIDSR reporting completeness steadily improved over time, with completeness being 90.2% in 2020 and 93.9% in 2021; conversely, monthly DHIS2 reporting completeness was 98.9% and 98.7% in 2020 and 2021, respectively. Weekly eIDSR reporting completeness and timeliness were highest in the very low epidemiological stratum. Annualized malaria incidence as reported by weekly eIDSR was 17.5% and 12.4% lower than reported by monthly DHIS2 in 2020 and 2021; for both 2020 and 2021, annualized incidence was similar across weekly and monthly data in the very low stratum. CONCLUSION: The concurrence of annualized weekly eIDSR and monthly DHIS2 reporting completeness, malaria cases and incidence in very low strata suggests that eIDSR could be useful tool for early outbreak detection, and the eIDSR platform could reliably be expanded by adding more indicators and modules for CBS in the very low epidemiological stratum.

Anthrax outbreaks in the humans - livestock and wildlife interface areas of Northern Tanzania: a retrospective record review 2006-2016.

BACKGROUND: Anthrax outbreaks in Tanzania have been reported from the human, livestock and wildlife sectors over several years, and is among the notifiable diseases. Despite frequent anthrax outbreaks, there is no comprehensive dataset indicating the magnitude and distribution of the disease in susceptible species. This study is a retrospective review of anthrax outbreaks from the human, livestock, and wildlife surveillance systems from 2006 to 2016. The objectives were to identify hotspot districts, describe anthrax epidemiology in the hotspot areas, evaluate the efficiency of the anthrax response systems and identify potential areas for further observational studies. METHODS: We prepared a spreadsheet template for a retrospective comprehensive record review at different surveillance levels in Tanzania. We captured data elements including demographic characteristics of different species, the name of health facility, and date of anthrax diagnosis. Also, we collected data on the date of specimen collection, species screened, type of laboratory test, laboratory results and the outcome recorded at the end of treatment in humans. After establishing the database, we produced maps in Quantum GIS software and transferred cleaned data to Stata software for supportive statistical analysis. RESULTS: Anthrax reported incidences over 4 years in humans were much higher in the Arusha region (7.88/100,000) followed by Kilimanjaro region (6.64/100,000) than other regions of Tanzania Mainland. The health facility based review from hotspot districts in parts of Arusha and Kilimanjaro regions from 2006 to 2016, identified 330 human anthrax cases from the selected health facilities in the two regions. Out of 161 livestock and 57 wildlife specimen tested, 103 and 18 respectively, were positive for anthrax. CONCLUSION: This study revealed that there is gross under-reporting in the existing surveillance systems which is an obstacle for estimating a true burden of anthrax in the hotspot districts. Repeated occurrences of anthrax in livestock, wildlife and humans in the same locations at the same time calls for the need to strengthen links and promote inter-disciplinary and multi-sectoral collaboration to enhance prevention and control measures under a One Health approach.

Clinical, Virologic, and Epidemiologic Characteristics of Dengue Outbreak, Dar es Salaam, Tanzania, 2014.

We investigated a dengue outbreak in Dar es Salaam, Tanzania, in 2014, that was caused by dengue virus (DENV) serotype 2. DENV infection was present in 101 (20.9%) of 483 patients. Patient age and location of residence were associated with infection. Seven (4.0%) of 176 patients were co-infected with malaria and DENV.

Severe Acute Respiratory Illness Deaths in Sub-Saharan Africa and the Role of Influenza: A Case Series From 8 Countries.

BACKGROUND: Data on causes of death due to respiratory illness in Africa are limited. METHODS: From January to April 2013, 28 African countries were invited to participate in a review of severe acute respiratory illness (SARI)-associated deaths identified from influenza surveillance during 2009-2012. RESULTS: Twenty-three countries (82%) responded, 11 (48%) collect mortality data, and 8 provided data. Data were collected from 37 714 SARI cases, and 3091 (8.2%; range by country, 5.1%-25.9%) tested positive for influenza virus. There were 1073 deaths (2.8%; range by country, 0.1%-5.3%) reported, among which influenza virus was detected in 57 (5.3%). Case-fatality proportion (CFP) was higher among countries with systematic death reporting than among those with sporadic reporting. The influenza-associated CFP was 1.8% (57 of 3091), compared with 2.9% (1016 of 34 623) for influenza virus-negative cases (P < .001). Among 834 deaths (77.7%) tested for other respiratory pathogens, rhinovirus (107 [12.8%]), adenovirus (64 [6.0%]), respiratory syncytial virus (60 [5.6%]), and Streptococcus pneumoniae (57 [5.3%]) were most commonly identified. Among 1073 deaths, 402 (37.5%) involved people aged 0-4 years, 462 (43.1%) involved people aged 5-49 years, and 209 (19.5%) involved people aged ≥50 years. CONCLUSIONS: Few African countries systematically collect data on outcomes of people hospitalized with respiratory illness. Stronger surveillance for deaths due to respiratory illness may identify risk groups for targeted vaccine use and other prevention strategies.

After-action review of rabies and anthrax outbreaks multisectoral response in Tanzania, challenges and lessons.

After-action review uses experiences gained from past events to adopt best practices, thereby improving future interventions. In December 2016 and late 2018, the government of Tanzania with support from partners responded to anthrax and rabies outbreaks in Arusha and Morogoro regions respectively. The One Health Coordination Desk (OHCD) of the Prime Minister's Office (PMO) later coordinated after-action reviews to review the multi-sectoral preparedness and response to the outbreaks. To establish and describe actions undertaken by the multi-sectoral investigation and response teams during planning and deployment, execution of field activities, and outbreak investigation and response, system best practices and deficiencies. These were cross-sectional surveys. Semi-structured, open and closed-ended questionnaire and focus group discussions were administered to collect information from responders at the national and subnational levels. It was found that the surveillance and response systems were weak at community level, lack of enforcement of public health laws including vaccination of livestock and domestic animals and joint preparedness efforts were generally undermined by differential disease surveillance capacities among sectors. Lack of resources in particular funds for supplies, transport and deployment of response teams contributed to many shortfalls. The findings underpin the importance of after-action reviews in identifying critical areas for improvement in multi-sectoral prevention and control of disease outbreaks. Main sectors under the coordination of the OHCD should include after action reviews in their plans and budget it as a tool to continuously assess and improve multi-sectoral preparedness and response to public health emergencies.

Narratives of veterinary drug use in northern Tanzania and consequences for drug stewardship strategies in low-income and middle-income countries.

INTRODUCTION: Awareness-raising campaigns play a central role in efforts to combat drug resistance. These campaigns assume that knowledge deficits drive poor practices that increase resistance. Therefore, increasing awareness will promote prudent practices and reduce resistance. However, most awareness campaigns have been developed and evaluated in high-income and public health settings. Consequently, it is not clear whether these campaigns are effective in low-income and middle-income countries and/or within animal health settings. METHODS: Focus group discussions and in-depth interviews were used to collect narratives of veterinary drug use among Maasai pastoralists (n=70), animal health professionals (n=10) and veterinary drug sellers (n=5). Thematic analysis was used to identify recurring themes across narratives and groups. RESULTS: Narratives of Maasai and animal health professionals indicated that Maasai treated their livestock with limited input from the professional sector and that non-prudent treatment practices were observed (eg, using antimicrobials as 'energizers'). Professionals linked these practices to knowledge and attitudinal deficits among the Maasai, while Maasai narratives highlighted the importance of climatic uncertainties and cultural beliefs surrounding veterinary care. CONCLUSION: Narratives of veterinary drug use from animal health professionals are consistent with the knowledge deficit assumption guiding awareness-raising efforts. In contrast, Maasai narratives highlight how animal health practices are patterned by cultural norms interacting with factors largely outside of Maasai control, including a constrained professional veterinary sector. If these cultural and structural contexts remain unconsidered in awareness-raising strategies, current campaigns are unlikely to motivate practices necessary to limit drug resistance, especially within low-income and middle-income settings.

Knowing Is Not Enough: A Mixed-Methods Study of Antimicrobial Resistance Knowledge, Attitudes, and Practises Among Maasai Pastoralists.

Global, national, and local efforts to limit antimicrobial resistance (AMR) often stress the importance of raising awareness among users, sellers, and prescribers of antimicrobial drugs. This emphasis is founded upon two assumptions. First, awareness is limited, particularly concerning the links between antimicrobial use (AMU) and AMR. Second, "filling the awareness gaps" will motivate practises that will limit AMR. The first assumption is supported by knowledge, attitudes, and practises (KAP) surveys but these same studies provide mixed support for the second, with several studies finding that knowledge and attitudes are not correlated with related practises. This disconnect may arise as these surveys typically do not collect data on the cultural or historical contexts that pattern AMU. To explore how these contexts impact KAP related to AMU and AMR, we use a mixed-methods approach to examine veterinary practises among Maasai pastoralists in Tanzania. We combine a quantitative KAP survey (N = 195 households) with extensive qualitative data from focus group discussions (N = 55 participants). Results document limited awareness of AMR but also find that knowledge and attitudes are not correlated with practise. Thematic analysis of qualitative data pointed to three reasons behind this disconnect, including (1) Maasai self-perceptions as veterinary experts, (2) the central role of livestock in Maasai culture, and (3) the use of ethnoveterinary knowledge in animal health treatment. We argue that mixed-method approaches will be critical to developing the targeted awareness campaigns needed to limit the emergence and transmission of AMR.

Development of Digital Health Messages for Rural Populations in Tanzania: Multi- and Interdisciplinary Approach.

BACKGROUND: Health workers have traditionally delivered health promotion and education to rural communities in the Global South in paper leaflet formats or orally. With the rise of digital technologies, health promotion and education can be provided in innovative and more effective formats, which are believed to have a higher impact on disease prevention and treatment. OBJECTIVE: The aim of this tutorial is to illustrate how a multi- and interdisciplinary approach can be applied in the design process of digital health messages for use in the Global South. METHODS: The multi- and interdisciplinary team of the Non-discriminating access for Digital Inclusion (DigI) project digitalized and customized available government-approved paper-based health promotion messages into a screen-suitable format. The team worked closely together and used its diverse expertise to develop digital health messages with disease-specific content in Tanzania's national language (Swahili) as well as English. The development process included the following phases: a local needs assessment; identification of government-approved health promotion materials in a nondigital format; identification of key health messages; creation of a practical and engaging story, easy to understand for the general public; drafting of a storyboard for an animated video with review, feedback, and revisions; forward and backward translation; audio recording of the story in both languages; finalization and presentation of the animations; development of relevant questions related to the health messages in each domain; and development of web and mobile apps to access the digital health messages. RESULTS: Between 2017 and 2019, we developed key health messages, quizzes, and animated health videos to address HIV/AIDS, tuberculosis, Taenia solium cysticercosis and taeniasis, and anthrax, all of which are of public health importance in Tanzania. Feedback from local stakeholders and test users was included in various phases of the process. The 4 videos and other content are available in local information spots on a digital health platform (DigI platform), established by the DigI project, in both Tanzanian Swahili and English. CONCLUSIONS: Our methodological multi- and interdisciplinary approach ensures that the digital health messages for the public are clear, high quality, and align with the government's objectives for health promotion. It also demonstrates the diversity of scientific disciplines required when collaborating on a digital health project. We recommend this approach to be applied to the development of other digital health messages for a wide range of diseases. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/25128.

Antimicrobial Use, Residues, Resistance and Governance in the Food and Agriculture Sectors, Tanzania.

All infections are potentially curable as long as the etiological agents are susceptible to antimicrobials. The increased rate at which antimicrobials are becoming ineffective is a global health risk of increasing concern that threatens withdrawal of beneficial antimicrobials for disease control. The increased demand for food of animal origin, in particular eggs, meat and milk has led to intensification and commercial production systems where excessive use and misuse of antimicrobials may prevail. Antimicrobials, handled and used by farmers and animal attendants with no formal education, may be predisposed to incorrect dosages, misuse, incorrect applications and non-adherence to withdrawal periods. This study was conducted to assess the regulatory roles and governance of antimicrobials, establish the pattern and extent of their use, evaluate the antimicrobial residues and resistance in the food animals and crop agriculture value chains, and relate these findings to existing strategies in place for combating the emergence of antimicrobial resistance in Tanzania. A multimethod approach (desk review, field study and interviews) was used. Relevant establishments were also visited. High levels of resistance to penicillin G, chloramphenicol, streptomycin and oxytetracycline have been reported, especially for Actinobacter pyogenes, Staphylococcus hyicus, Staphylococcus intermedius and Staphylococcus aureus from dairy cattle with mastitis and in humans. Similar trends were found in poultry where eggs and meat are contaminated with Escherichia coli strains resistant to amoxicillin + clavulanate, sulphamethoxazole and neomycin. An increasing trend of emerging multidrug resistant E. coli, Klebsiella pneumoniae, Staphylococcus aureus and Salmonella was also found in food animals. An increase in methicillin resistant Staphlococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL) in the livestock sector in Tanzania have been reported. The pathogens isolated in animals were resistant to ampicillin, augmentin, gentamicin, co-trimoxazole, tetracycline, amoxicillin, streptomycin, nalidixic acid, azithromycin, chloramphenicol, tylosin, erythromycin, cefuroxime, norfloxacin and ciprofloxacin. An increased usage of antimicrobials for prophylaxis, and therapeutics against pathogens and for growth promotion in livestock, aquaculture and crop production were observed. A One Health strategic approach is advocated to combat antimicrobial resistance (AMR) in the food and agriculture sectors in Tanzania. Practical recommendations include (a) legislation review and implementation; (b) antimicrobial use (AMU), AMR and antimicrobial residue (AR) awareness and advocacy among stakeholders along the value chain; (c) strengthening of surveillance and monitoring programs for AMU, AMR and AR; (d) enhanced development and use of rapid and innovative diagnostic tests and the promotion of biosecurity principles; and (e) good husbandry practices. The utilization of this information to improve public health policies and reduce the burden of AMR will be beneficial.

"We are doctors": Drivers of animal health practices among Maasai pastoralists and implications for antimicrobial use and antimicrobial resistance.

Animal health service providers can play an important role in limiting drug resistance by promoting responsible and prudent use of veterinary drugs. Recognizing this potential, international agencies and governments have called for these providers to receive drug stewardship training, particularly providers in low- and middle-income countries where top-down regulations (e.g., national regulation of veterinary prescriptions) are largely unfeasible. The success of these stewardship trainings to promote responsible and prudent use will depend on many factors, including understanding how livestock-keeping communities currently interact with animal health service providers. Here, we use a mixed methods approach to identify and understand animal health seeking practices among Maasai pastoralists in Tanzania. Combining qualitative interviews (N = 31) and structured surveys (N = 195), we show the majority of Maasai respondents (≈80 %) do not frequently consult animal health service providers with most relying on advice from family and friends. Logistic regression models of health seeking practices find that increasing age, education, observance of treatment failure, and herd disease burdens are associated with greater odds of seeking out health services. Quantitative results were supported by data from focus group discussions and in-depth interviews that showed Maasai view animal health service providers as measures of last resort, whose input is largely sought after self-treatment with veterinary drugs fail. We argue patterns of animal health seeking among the Maasai are partially the consequence of their high confidence in their own abilities in livestock disease and treatment and generally low confidence in the skills of animal health service providers. We link this high sense of self-efficacy to the culturally engrained process by which Maasai develop mastery in animal health and how the roles and norms in Maasai culture surrounding animal health influence Maasai perceptions of animal health professionals. Our results highlight the need for more research to understand Maasai perceptions of animal health service providers as well as the knowledge, attitudes, and practices of these providers. Finally, our study emphasizes that the success of drug stewardship trainings will require efforts to first understand the cultural and historical contexts driving health seeking practices that impact perceptions of animal health service providers and animal health practices more generally.

Multisectoral cost analysis of a human and livestock anthrax outbreak in Songwe Region, Tanzania (December 2018-January 2019), using a novel Outbreak Costing Tool.

OBJECTIVES: We applied a novel Outbreak Costing Tool (OCT), developed by the US Centers for Disease Control and Prevention (CDC), to estimate the costs of investigating and responding to an anthrax outbreak in Tanzania. We also evaluated the OCT's overall utility in its application to a multisectoral outbreak response. METHODS: We collected data on direct costs associated with a human and animal anthrax outbreak in Songwe Region (December 2018 to January 2019) using structured questionnaires from key-informants. We performed a cost analysis by entering direct costs data into the OCT, grouped into seven cost categories: labor, office, travel and transport, communication, laboratory support, medical countermeasures, and consultancies. RESULTS: The total cost for investigating and responding to this outbreak was estimated at 102,232 United States dollars (USD), with travel and transport identified as the highest cost category (62,536 USD) and communication and consultancies as the lowest, with no expenditure, for the combined human and animal health sectors. CONCLUSIONS: Multisectoral investigation and response may become complex due to coordination challenges, thus allowing escalation of public health impacts. A standardized framework for collecting and analysing cost data is vital to understanding the nature of outbreaks, in anticipatory planning, in outbreak investigation and in reducing time to intervention. Pre-emptive use of the OCT will also reduce overall and specific (response period) intervention costs for the disease. Additional aggregation of the costs by government ministries, departments and tiers will improve the use of the tool to enhance sectoral budget planning for disease outbreaks in a multisectoral response.

Environmental determinants influencing anthrax distribution in Queen Elizabeth Protected Area, Western Uganda.

Bacillus anthracis, the bacteria that causes anthrax, a disease that primarily affects herbivorous animals, is a soil borne endospore-forming microbe. Environmental distribution of viable spores determines risky landscapes for herbivore exposure and subsequent anthrax outbreaks. Spore survival and longevity depends on suitable conditions in its environment. Anthrax is endemic in Queen Elizabeth Protected Area in western Uganda. Periodic historical outbreaks with significant wildlife losses date to 1950s, but B. anthracis ecological niche in the ecosystem is poorly understood. This study used the Maximum Entropy modeling algorithm method to predict suitable niche and environmental conditions that may support anthrax distribution and spore survival. Model inputs comprised 471 presence-only anthrax occurrence data from park management records of 1956-2010, and 11 predictor variables derived from the World Climatic and Africa Soil Grids online resources, selected considering the ecology of anthrax. The findings revealed predicted suitable niche favoring survival and distribution of anthrax spores as a narrow-restricted corridor within the study area, defined by hot-dry climatic conditions with alkaline soils rich in potassium and calcium. A mean test AUC of 0.94 and predicted probability of 0.93 for anthrax presence were registered. The five most important predictor variables that accounted for 93.8% of model variability were annual precipitation (70.1%), exchangeable potassium (12.6%), annual mean temperature (4.3%), soil pH (3.7%) and calcium (3.1%). The predicted suitable soil properties likely originate from existing sedimentary calcareous gypsum rocks. This has implications for long-term presence of B. anthracis spores and might explain the long history of anthrax experienced in the area. However, occurrence of suitable niche as a restricted hot zone offers opportunities for targeted anthrax surveillance, response and establishment of monitoring strategies in QEPA.

Ecological niche modeling as a tool for prediction of the potential geographic distribution of Bacillus anthracis spores in Tanzania.

INTRODUCTION: Anthrax is caused by the spore-forming, Gram-positive bacterium Bacillus anthracis. The aim of this study was to predict the potential distribution of B. anthracis in Tanzania and produce epidemiological evidence for the management of anthrax outbreaks in the country. METHODS: The Maxent algorithm was used to predict areas at risk of anthrax outbreaks based on the occurrence and environmental data in Arusha and Kilimanjaro regions; the model was later transferred to predict the entire country. Seventy percent of the occurrence data were used to train the model, while 30% were used for model evaluation. RESULTS: Four regions of northern Tanzania are predicted to have a high risk for anthrax outbreaks, while the southern and western regions had low-risk areas. Soil type (56.5%), soil pH (23.7%), and isothermally (10.4%) were the most important variables for the model prediction, and the most significant soil types were solonetz, fluvisols, and lithosols. CONCLUSIONS: A strong risk level across districts of the Tanzania mainland was identified in this study. A total of 18 districts in Tanzania Mainland are predicted to be at very high risk of an anthrax outbreak occurrence. These findings are important for policymakers to effectively mount targeted control measures for anthrax outbreaks in Tanzania.

Building a functional national One Health platform: the case of Tanzania.

BACKGROUND: The USAID Preparedness and Response (P&R) project's publication on Multisectoral Coordination that Works identified five dimensions most critical to creating effective and sustainable One Health platforms: political commitment, institutional structure, management and coordination capacity, technical and financial resources, and joint planning and implementation. This case study describes Tanzania experience in using these dimensions to establish a functional One Health platform. The main objective of this case study was to document the process of institutionalizing the One Health approach in Tanzania. METHODS: An analysis of the process used to establish and institutionalize the MCM in Tanzania through addressing the five dimensions mentioned above was conducted between August 2018 and January 2019. Progress activity reports, annual reports and minutes of meetings and consultations regarding the establishment of the Tanzania national One Health platform were examined. Relevant One Health publications were studied as reference material. RESULTS: This case study illustrates the time and level of effort required of multiple partners to build a functional multi-sectoral coordinating mechanism (MCM). Key facilitating factors were identified and the importance of involving policy and decision makers at all stages of the process to facilitate policy decisions and the institutionalization process was underscored. The need for molding the implementation process using lessons learnt along the way -- "sailing the ship as it was being built" -- is demonstrated. CONCLUSIONS: Tanzania now has a functioning and institutionalized MCM with a sound institutional structure and capacity to prevent, detect early and respond to health events. The path to its establishment required the patient commitment of a core group of One Health champions and stakeholders along the way to examine carefully and iteratively how best to structure productive multisectoral coordination in the country. The five dimensions identified by the Preparedness and Response project may provide useful guidance to other countries working to establish functional MCM.

Risk factors for human cutaneous anthrax outbreaks in the hotspot districts of Northern Tanzania: an unmatched case-control study.

Bacillus anthracis is an aerobic, Gram-positive and spore-forming bacterium, which causes anthrax in herbivores. Humans get infected after coming into contact with infected animals' products. An unmatched case-control study was conducted to identify the importance of demographic, biological and/or behavioural factors associated with human cutaneous anthrax outbreaks in the hotspot areas of Northern Tanzania. A semi-structured questionnaire was administered to both cases and controls. The age range of participants was 1-80 years with a median age of 32 years. In the younger group (1-20 years), the odds of being infected were 25 times higher in the exposed group compared to the unexposed group (OR= 25, 95% CI = 1.5-410). By contrast, the odds of exposure in the old group (≥20 years) were three times lower in the exposed group compared to the unexposed group (OR = 3.2, 95% CI = 1.28-8.00). Demographic characteristics, sleeping on animal's skins, contacting with infected carcasses through skinning and butchering, and not having formal education were linked to exposure for anthrax infection. Hence, a One Health approach is inevitable for the prevention and control of anthrax outbreaks in the hotspot areas of Northern Tanzania.

Sensitivity, Specificity, and Public-Health Utility of Clinical Case Definitions Based on the Signs and Symptoms of Cholera in Africa.

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 Vibrio cholerae 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.

The African cholera surveillance network (Africhol) consortium meeting, 10-11 June 2015, Lomé, Togo.

The fifth annual meeting of the African cholera surveillance network (Africhol) took place on 10-11 June 2015 in Lomé, Togo. Together with international partners, representatives from the 11 member countries -Cameroon, Côte d'Ivoire, Democratic Republic of Congo, Guinea, Kenya, Mozambique, Nigeria, Tanzania, Togo, Uganda, Zimbabwe- and an invited country (Malawi) shared their experience. The meeting featured three sessions: i) cholera surveillance, prevention and control in participating countries, ii) cholera surveillance methodology, such as cholera mapping, cost-effectiveness studies and the issue of overlapping epidemics from different diseases, iii) cholera laboratory diagnostics tools and capacity building. The meeting has greatly benefitted from the input of technical expertise from participating institutions and the observations emerging from the meeting should enable national teams to make recommendations to their respective governments on the most appropriate and effective measures to be taken for the prevention and control of cholera. Recommendations for future activities included collecting precise burden estimates in surveillance sites; modeling cholera burden for Africa; setting up cross-border collaborations; strengthening laboratory capacity for the confirmation of suspected cholera cases and for vaccine impact assessment in settings where oral cholera vaccine would be used; adapting cholera surveillance to concurrent issues (e.g., Ebola); and developing national cholera control plans including rationale vaccination strategies together with other preventive and control measures such as improvements in water, sanitation and hygiene (WASH).