title: Cholera at the crossroads: the association between endemic cholera and national access to improved water sources and sanitation.
abstract: 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.
authors.affiliation: Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia bnygren@cdc.gov.
authors.forename: Benjamin L
authors.initials: BL
authors.lastname: Nygren
authors.affiliation: Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Anna J
authors.initials: AJ
authors.lastname: Blackstock
authors.affiliation: Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Mintz
mesh_terms: D019540:Area Under Curve; D002771:Cholera / Q000453:epidemiology*; D060766:Drinking Water / Q000382:microbiology; D019353:Endemic Diseases; D005506:Food Contamination; D005516:Food Microbiology; D005517:Foodborne Diseases / Q000453:epidemiology*; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D016015:Logistic Models; D012499:Sanitation / Q000379:methods*; D012680:Sensitivity and Specificity; D014871:Water Microbiology; D014944:World Health Organization
chemical_list: D060766:Drinking Water