title: Strategies to Prevent Cholera Introduction during International Personnel Deployments: A Computational Modeling Analysis Based on the 2010 Haiti Outbreak.
abstract: BACKGROUND
  Introduction of Vibrio cholerae to Haiti during the deployment of United Nations (UN) peacekeepers in 2010 resulted in one of the largest cholera epidemics of the modern era. Following the outbreak, a UN-commissioned independent panel recommended three pre-deployment intervention strategies to minimize the risk of cholera introduction in future peacekeeping operations: screening for V. cholerae carriage, administering prophylactic antimicrobial chemotherapies, or immunizing with oral cholera vaccines. However, uncertainty regarding the effectiveness of these approaches has forestalled their implementation by the UN. We assessed how the interventions would have impacted the likelihood of the Haiti cholera epidemic.
  
  
  RESULTS
  We developed a stochastic model for cholera importation and transmission, fitted to reported cases during the first weeks of the 2010 outbreak in Haiti. Using this model, we estimated that diagnostic screening reduces the probability of cases occurring by 82% (95% credible interval: 75%, 85%); however, false-positive test outcomes may hamper this approach. Antimicrobial chemoprophylaxis at time of departure and oral cholera vaccination reduce the probability of cases by 50% (41%, 57%) and by up to 61% (58%, 63%), respectively. Chemoprophylaxis beginning 1 wk before departure confers a 91% (78%, 96%) reduction independently, and up to a 98% reduction (94%, 99%) if coupled with vaccination. These results are not sensitive to assumptions about the background cholera incidence rate in the endemic troop-sending country. Further research is needed to (1) validate the sensitivity and specificity of rapid test approaches for detecting asymptomatic carriage, (2) compare prophylactic efficacy across antimicrobial regimens, and (3) quantify the impact of oral cholera vaccine on transmission from asymptomatic carriers.
  
  
  CONCLUSIONS
  Screening, chemoprophylaxis, and vaccination are all effective strategies to prevent cholera introduction during large-scale personnel deployments such as that precipitating the 2010 Haiti outbreak. Antimicrobial chemoprophylaxis was estimated to provide the greatest protection at the lowest cost among the approaches recently evaluated by the UN.
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Lewnard
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America.|Global Health Justice Partnership, Yale University, New Haven, Connecticut, Untied States of America.
authors.forename: Marina
authors.initials: M
authors.lastname: Antillón
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America.|Global Health Justice Partnership, Yale University, New Haven, Connecticut, Untied States of America.|Yale Law School, New Haven, Connecticut, United States of America.
authors.forename: Gregg
authors.initials: G
authors.lastname: Gonsalves
authors.affiliation: Global Health Justice Partnership, Yale University, New Haven, Connecticut, Untied States of America.|Yale Law School, New Haven, Connecticut, United States of America.|Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Miller
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America.|Global Health Justice Partnership, Yale University, New Haven, Connecticut, Untied States of America.|Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Salvador, Brazil.
authors.forename: Albert I
authors.initials: AI
authors.lastname: Ko
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America.
authors.forename: Virginia E
authors.initials: VE
authors.lastname: Pitzer
mesh_terms: D002771:Cholera / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control*; D022121:Cholera Vaccines / Q000627:therapeutic use; D003198:Computer Simulation; D004196:Disease Outbreaks / Q000517:prevention & control*; D005260:Female; D006205:Haiti / Q000453:epidemiology; D006801:Humans; D038622:Internationality; D008297:Male; D010561:Personnel Staffing and Scheduling; D014480:United Nations; D014611:Vaccination / Q000379:methods
chemical_list: D022121:Cholera Vaccines
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