title: Interaction between climatic, environmental, and demographic factors on cholera outbreaks in Kenya.
abstract: BACKGROUND
  Cholera remains an important public health concern in developing countries including Kenya where 11,769 cases and 274 deaths were reported in 2009 according to the World Health Organization (WHO). This ecological study investigates the impact of various climatic, environmental, and demographic variables on the spatial distribution of cholera cases in Kenya.
  
  
  METHODS
  District-level data was gathered from Kenya's Division of Disease Surveillance and Response, the Meteorological Department, and the National Bureau of Statistics. The data included the entire population of Kenya from 1999 to 2009.
  
  
  RESULTS
  Multivariate analyses showed that districts had an increased risk of cholera outbreaks when a greater proportion of the population lived more than five kilometers from a health facility (RR: 1.025 per 1% increase; 95% CI: 1.010, 1.039), bordered a body of water (RR: 5.5; 95% CI: 2.472, 12.404), experienced increased rainfall from October to December (RR: 1.003 per 1 mm increase; 95% CI: 1.001, 1.005), and experienced decreased rainfall from April to June (RR: 0.996 per 1 mm increase; 95% CI: 0.992, 0.999). There was no detectable association between cholera and population density, poverty, availability of piped water, waste disposal methods, rainfall from January to March, or rainfall from July to September.
  
  
  CONCLUSIONS
  Bordering a large body of water, lack of health facilities nearby, and changes in rainfall were significantly associated with an increased risk of cholera in Kenya.
authors.affiliation: School of Medicine, Department of Public Health and Preventive Medicine, St. George's University (SGU), West Indies, Grenada.
authors.forename: James D
authors.initials: JD
authors.lastname: Stoltzfus
authors.affiliation: African Medical and Research Foundation (AMREF), Nairobi, Kenya.
authors.forename: Jane Y
authors.initials: JY
authors.lastname: Carter
authors.affiliation: Center for Global Health, College of Health Sciences, Old Dominion University, Norfolk, VA USA.
authors.forename: Muge
authors.initials: M
authors.lastname: Akpinar-Elci
authors.affiliation: African Medical and Research Foundation (AMREF), Nairobi, Kenya.
authors.forename: Martin
authors.initials: M
authors.lastname: Matu
authors.affiliation: African Medical and Research Foundation (AMREF), Nairobi, Kenya.
authors.forename: Victoria
authors.initials: V
authors.lastname: Kimotho
authors.affiliation: School of Medicine, Department of Public Health and Preventive Medicine, St. George's University (SGU), West Indies, Grenada.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Giganti
authors.affiliation: Center for Global Health, College of Health Sciences, Old Dominion University, Norfolk, VA USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Langat
authors.affiliation: School of Medicine, Department of Public Health and Preventive Medicine, St. George's University (SGU), West Indies, Grenada.
authors.forename: Omur Cinar
authors.initials: OC
authors.lastname: Elci
keywords: Cholera; Education; Health infrastructure; Population density; Poverty; Rainfall; Waste disposal; Water supply