title: High-resolution spatial analysis of cholera patients reported in Artibonite department, Haiti in 2010-2011.
abstract: BACKGROUND
  Cholera is caused by Vibrio cholerae, and is transmitted through fecal-oral contact. Infection occurs after the ingestion of the bacteria and is usually asymptomatic. In a minority of cases, it causes acute diarrhea and vomiting, which can lead to potentially fatal severe dehydration, especially in the absence of appropriate medical care. Immunity occurs after infection and typically lasts 6-36 months. Cholera is responsible for outbreaks in many African and Asian developing countries, and caused localised and episodic epidemics in South America until the early 1990s. Haiti, despite its low socioeconomic status and poor sanitation, had never reported cholera before the recent outbreak that started in October 2010, with over 720,000 cases and over 8700 deaths (Case fatality rate: 1.2%) through 8 december 2014. So far, this outbreak has seen 3 epidemic peaks, and it is expected that cholera will remain in Haiti for some time.
  
  
  RESULTS
  To trace the path of the early epidemic and to identify hot spots and potential transmission hubs during peaks, we examined the spatial distribution of cholera patients during the first two peaks in Artibonite, the second-most populous department of Haiti. We extracted the geographic origin of 84,000 patients treated in local health facilities between October 2010 and December 2011 and mapped these addresses to 63 rural communal sections and 9 urban cities. Spatial and cluster analysis showed that during the first peak, cholera spread along the Artibonite River and the main roads, and sub-communal attack rates ranged from 0.1% to 10.7%. During the second peak, remote mountain areas were most affected, although sometimes to very different degrees even in closely neighboring locations. Sub-communal attack rates during the second peak ranged from 0.2% to 13.7%. The relative risks at the sub-communal level during the second phase showed an inverse pattern compared to the first phase.
  
  
  CONCLUSIONS
  These findings demonstrate the value of high-resolution mapping for pinpointing locations most affected by cholera, and in the future could help prioritize the places in need of interventions such as improvement of sanitation and vaccination. The findings also describe spatio-temporal transmission patterns of the epidemic in a cholera-naïve country such as Haiti. By identifying transmission hubs, it is possible to target prevention strategies that, over time, could reduce transmission of the disease and eventually eliminate cholera in Haiti.
authors.affiliation: Epicentre, Paris, France. Electronic address: mayac.allan@laposte.net.
authors.forename: Maya
authors.initials: M
authors.lastname: Allan
authors.affiliation: Epicentre, Paris, France. Electronic address: francesco.grandesso@epicentre.msf.org.
authors.forename: Francesco
authors.initials: F
authors.lastname: Grandesso
authors.affiliation: Artibonite Surveillance Department, MSPP, Gonaïves, Haiti. Electronic address: pierreronald29@yahoo.fr.
authors.forename: Ronald
authors.initials: R
authors.lastname: Pierre
authors.affiliation: Surveillance Department, DELR, Port-au-Prince, Haiti. Electronic address: corgamsa@hotmail.com.
authors.forename: Roc
authors.initials: R
authors.lastname: Magloire
authors.affiliation: Epicentre, Paris, France. Electronic address: matthew.coldiron@epicentre.msf.org.
authors.forename: Matthew
authors.initials: M
authors.lastname: Coldiron
authors.affiliation: Epicentre, Paris, France; European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden. Electronic address: imartinez@epicentre.msf.org.
authors.forename: Isabel
authors.initials: I
authors.lastname: Martinez-Pino
authors.affiliation: Médecins Sans Frontières, Paris, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Goffeau
authors.affiliation: Médecins Sans Frontières, Paris, France.
authors.forename: Romain
authors.initials: R
authors.lastname: Gitenet
authors.affiliation: Médecins Sans Frontières, New York, NY, USA. Electronic address: gwenola.francois@newyork.msf.org.
authors.forename: Gwenola
authors.initials: G
authors.lastname: François
authors.affiliation: Médecins Sans Frontières, New York, NY, USA. Electronic address: david.olson@newyork.msf.org.
authors.forename: David
authors.initials: D
authors.lastname: Olson
authors.affiliation: Epicentre, Paris, France. Electronic address: klaudia.porten@epicentre.msf.org.
authors.forename: Klaudia
authors.initials: K
authors.lastname: Porten
authors.affiliation: Epicentre, Paris, France. Electronic address: francisco.luquero@epicentre.msf.org.
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Luquero
mesh_terms: D002771:Cholera / Q000453:epidemiology*; D016000:Cluster Analysis; D004196:Disease Outbreaks / Q000706:statistics & numerical data; D058872:Epidemics / Q000706:statistics & numerical data*; D006205:Haiti / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D012306:Risk; D062206:Spatial Analysis
keywords: Cholera; Haiti; Kulldorf; Relative risk; Spatial analysis