The spread of cholera in western Democratic Republic of the Congo is not unidirectional from East-West: a spatiotemporal analysis, 1973-2018

Abstract

Background: Cholera outbreaks in western Democratic Republic of the Congo (DRC) are thought to be primarily the result of westward spread of cases from the Great Lakes Region. However, other patterns of spatial spread in this part of the country should not be excluded. The aim of this study was to explore alternative routes of spatial spread in western DRC.

Methods: A literature review was conducted to reconstruct major outbreak expansions of cholera in western DRC since its introduction in 1973. We also collected data on cholera cases reported at the health zone (HZ) scale by the national surveillance system during 2000-2018. Based on data from routine disease surveillance, we identified two subperiods (week 45, 2012-week 42, 2013 and week 40, 2017-week 52, 2018) for which the retrospective space-time permutation scan statistic was implemented to detect spatiotemporal clusters of cholera cases and then to infer the spread patterns in western DRC other than that described in the literature.

Results: Beyond westward and cross-border spread in the West Congo Basin from the Great Lakes Region, other dynamics of cholera epidemic propagation were observed from neighboring countries, such as Angola, to non-endemic provinces of southwestern DRC. Space-time clustering analyses sequentially detected clusters of cholera cases from southwestern DRC to the northern provinces, demonstrating a downstream-to-upstream spread along the Congo River.

Conclusions: The spread of cholera in western DRC is not one-sided. There are other patterns of spatial spread, including a propagation from downstream to upstream areas along the Congo River, to be considered as preferential trajectories of cholera in western DRC.

Keywords: Cholera; Clusters; Democratic Republic of the Congo; Epidemic spread; Spatiotemporal analysis; Vibrio cholerae.

Fig. 1

Administrative map of the DRC

Fig. 2

Major outbreak expansions of cholera in western DRC documented since its introduction in 1973

Fig. 3

Weekly notification of suspected cholera cases, western provinces of DRC, 2000–2018. From top to bottom: Tshopo, Mongala, Equateur, Maï Ndombe, Kwilu, Kinshasa, Kongo Central. Tshopo province has been included to highlight its non-involvement in the dynamics of cholera outbreaks in western DRC during the periods identified for the spatiotemporal cluster detection analysis. The grey rectangles correspond the periods 2011–2012 and 2016–2017

Fig. 4

Spatiotemporal clusters of cholera cases, western DRC, week 45, 2012–week 42, 2013

Fig. 5

Spatiotemporal clusters of cholera cases, western DRC, week 40, 2017–week 52, 2018