An approach to integrate population mobility patterns and sociocultural factors in communicable disease preparedness and response.

Complex human movement patterns driven by a range of economic, health, social, and environmental factors influence communicable disease spread. Further, cross-border movement impacts disparate public health systems of neighboring countries, making an effective response to disease importation or exportation more challenging. Despite the array of quantitative techniques and social science approaches available to analyze movement patterns, there continues to be a dearth of methods within the applied public health setting to gather and use information about community-level mobility dynamics. Population Connectivity Across Borders (PopCAB) is a rapidly-deployable toolkit to characterize multisectoral movement patterns through community engagement using focus group discussions or key informant interviews, each with participatory mapping, and apply the results to tailor preparedness and response strategies. The Togo and Benin Ministries of Health (MOH), in collaboration with the Abidjan Lagos Corridor Organization and the US Centers for Disease Control and Prevention, adapted and applied PopCAB to inform cross-border preparedness and response strategies for multinational Lassa fever outbreaks. Initially, the team implemented binational, national-level PopCAB activities in March 2017, highlighting details about a circular migration pathway across northern Togo, Benin, and Nigeria. After applying those results to respond to a cross-border Lassa fever outbreak in February 2018, the team designed an expanded PopCAB initiative in April 2018. In eight days, they trained 54 MOH staff who implemented 21 PopCAB focus group discussions in 14 cities with 224 community-level participants representing six stakeholder groups. Using the newly-identified 167 points of interest and 176 routes associated with a circular migration pathway across Togo, Benin, and Nigeria, the Togo and Benin MOH refined their cross-border information sharing and collaboration processes for Lassa fever and other communicable diseases, selected health facilities with increased community connectivity for enhanced training, and identified techniques to better integrate traditional healers in surveillance and community education strategies. They also integrated the final toolkit in national- and district-level public health preparedness plans. Integrating PopCAB in public health practice to better understand and accommodate population movement patterns can help countries mitigate the international spread of disease in support of improved global health security and International Health Regulations requirements.

Improving Cross-Border Preparedness and Response: Lessons Learned from 3 Lassa Fever Outbreaks Across Benin, Nigeria, and Togo, 2017-2019.

Long-standing cultural, economic, and political relationships among Benin, Nigeria, and Togo contribute to the complexity of their cross-border connectivity. The associated human movement increases the risk of international spread of communicable disease. The Benin and Togo ministries of health and the Nigeria Centre for Disease Control, in collaboration with the Abidjan Lagos Corridor Organization (a 5-country intergovernmental organization) and the US Centers for Disease Control and Prevention, sought to minimize the risk of cross-border outbreaks by defining and implementing procedures for binational and multinational public health collaboration. Through 2 multinational meetings, regular district-level binational meetings, and fieldwork to characterize population movement and connectivity patterns, the countries improved cross-border public health coordination. Across 3 sequential cross-border Lassa fever outbreaks identified in Benin or Togo between February 2017 and March 2019, the 3 countries improved their collection and sharing of patients' cross-border travel histories, shortened the time between case identification and cross-border information sharing, and streamlined multinational coordination during response efforts. Notably, they refined collaborative efforts using lessons learned from the January to March 2018 Benin outbreak, which had a 100% case fatality rate among the 5 laboratory-confirmed cases, 3 of whom migrated from Nigeria across porous borders when ill. Aligning countries' expectations for sharing public health information would assist in reducing the international spread of communicable diseases by facilitating coordinated preparedness and responses strategies. Additionally, these binational and multinational strategies could be made more effective by tailoring them to the unique cultural connections and population movement patterns in the region.

Cholera Incidence and Mortality in Sub-Saharan African Sites during Multi-country Surveillance.

BACKGROUND: Cholera burden in Africa remains unknown, often because of weak national surveillance systems. We analyzed data from the African Cholera Surveillance Network (www.africhol.org). METHODS/ PRINCIPAL FINDINGS: During June 2011-December 2013, we conducted enhanced surveillance in seven zones and four outbreak sites in Togo, the Democratic Republic of Congo (DRC), Guinea, Uganda, Mozambique and Cote d'Ivoire. All health facilities treating cholera cases were included. Cholera incidences were calculated using culture-confirmed cholera cases and culture-confirmed cholera cases corrected for lack of culture testing usually due to overwhelmed health systems and imperfect test sensitivity. Of 13,377 reported suspected cases, 34% occurred in Conakry, Guinea, 47% in Goma, DRC, and 19% in the remaining sites. From 0-40% of suspected cases were aged under five years and from 0.3-86% had rice water stools. Within surveillance zones, 0-37% of suspected cases had confirmed cholera compared to 27-38% during outbreaks. Annual confirmed incidence per 10,000 population was <0.5 in surveillance zones, except Goma where it was 4.6. Goma and Conakry had corrected incidences of 20.2 and 5.8 respectively, while the other zones a median of 0.3. During outbreaks, corrected incidence varied from 2.6 to 13.0. Case fatality ratios ranged from 0-10% (median, 1%) by country. CONCLUSIONS/SIGNIFICANCE: Across different African epidemiological contexts, substantial variation occurred in cholera incidence, age distribution, clinical presentation, culture confirmation, and testing frequency. These results can help guide preventive activities, including vaccine use.

National surveillance data on the epidemiology of cholera in Togo.

BACKGROUND: Togo is a cholera-endemic country bordered by other countries where this disease is endemic. We describe the epidemiology of cholera in Togo, using national surveillance data. METHODS: We reviewed national surveillance data housed in the National Ministry of Health. Districts submitted reports of summary weekly case counts and deaths at the national level. Data were available at the district level during 2008-2010 and at the national level from 1996 onward. Microbiological confirmation usually was not performed, and case identification was based on clinical suspicion. RESULTS: From 1996 through 2010, Togo had 12 676 reported cholera cases and 554 deaths. Annual national cholera incidence varied from 0.9 to 66 cases per 100 000 population, with little variation except for 2 large epidemics during 1998 and 2001. The case-fatality ratio declined from 12%-17% during 1996-1997 to <1% during 2008-2010. During 2008-2010, 85% of 26 district-level outbreaks occurred in the capital Lomé or the coastal Maritime Region. The average outbreak duration was 6 weeks, and only 2 lasted >15 weeks. DISCUSSION: While cholera control remains elusive in Togo, reductions in case-fatality ratios have occurred, possibly due to improvements in case management. The short duration of outbreaks may preclude reactive vaccination; however, the restricted geographic location may make preventive immunization attractive.