title: Cholera ante portas - The re-emergence of cholera in Kinshasa after a ten-year hiatus.
abstract: BACKGROUND
  Cholera is an endemic disease in certain well-defined areas in the east of the Democratic Republic of Congo (DRC). The west of the country, including the mega-city Kinshasa, has been free of cases since mid 2001 when the last outbreak ended.
  
  
  RESULTS
  We used routinely collected passive surveillance data to construct epidemic curves of the cholera cases and map the spatio-temporal progress of the disease during the first 47 weeks of 2011. We compared the spatial distribution of disease spread to that which occurred in the last cholera epidemic in Kinshasa between 1996 and 2001. To better understand previous determinants of cholera spread in this region, we conducted a correlation analysis to assess the impact of rainfall on weekly health zone cholera case counts between December 1998 and March 2001 and a Generalized Linear Model (GLM) regression analysis to identify factors that have been associated with the most vulnerable health zones within Kinshasa between October 1998 and June 1999. In February 2011, cholera reemerged in a region surrounding Kisangani and gradually spread westwards following the course of the Congo River to Kinshasa, home to 10 million people. Ten sampled isolates were confirmed to be Vibrio cholerae O1, biotype El Tor, serotype Inaba, resistant to trimethoprim-sulfa, furazolidone, nalidixic acid, sulfisoxaole, and streptomycin, and intermediate resistant to Chloramphenicol. An analysis of a previous outbreak in Kinshasa shows that rainfall was correlated with case counts and that health zone population densities as well as fishing and trade activities were predictors of case counts.
  
  
  CONCLUSIONS
  Cholera is particularly difficult to tackle in the DRC. Given the duration of the rainy season and increased riverine traffic from the eastern provinces in late 2011, we expect further increases in cholera in the coming months and especially within the mega-city Kinshasa. We urge all partners involved in the response to remain alert.Didier Bompangue and Silvan Vesenbeckh contributed equally to this work. *corresponding author: Silvan Vesenbeckh, Harvard School of Public Health (vesenbeckh@gmail.com)Didier Bompangue is Associate Professor in the Department of Microbiology (University of Kinshasa) andEpidemiologist in the DRC Ministry of Health. He was involved in the investigations of the described outbreak since February 2011.
authors.affiliation: Laboratoire Chrono-environnement, UMR6249, CNRS, University of Franche-Comté, Place Leclerc 25030 Besançon, France. Laboratory of Microbiology, Faculty of Medicine, University of Kinshasa, BP: 834, Kinshasa, Democratic Republic of Congo. Direction de Lutte contre la Maladie, Ministry of Public Health, Av. de la Justice 39, Gombe I, Kinshasa, Democratic Republic of Congo.;  Harvard School of Public Health, Center for Communicable Disease Dynamics, 677 Huntington Avenue, Boston MA 02115, USA. Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis Street, Boston MA 02115, USA;  Laboratoire Chrono-environnement, UMR6249, CNRS, University of Franche-Comté, Place Leclerc 25030 Besançon, France;  Harvard School of Public Health, Department of Global Health and Population, 677 Huntington Avenue, Boston MA 02115, USA;  Laboratory of Microbiology, Faculty of Medicine, University of Kinshasa, BP: 834, Kinshasa, Democratic Republic of Congo;  Direction de Lutte contre la Maladie, Ministry of Public Health, Av. de la Justice 39, Gombe I, Kinshasa, Democratic Republic of Congo and  Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis Street, Boston MA 02115, USA. Harvard School of Public Health, Department of Epidemiology, 677 Huntington Avenue, Boston MA 02115, USA.
authors.forename: Didier
authors.initials: D
authors.lastname: Bompangue
authors.forename: Silvan Manuel
authors.initials: SM
authors.lastname: Vesenbeckh
authors.forename: Patrick
authors.initials: P
authors.lastname: Giraudoux
authors.forename: Marcia
authors.initials: M
authors.lastname: Castro
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Muyembe
authors.forename: Benoît
authors.initials: B
authors.lastname: Kebela Ilunga
authors.forename: Megan
authors.initials: M
authors.lastname: Murray