Clinical surveillance systems obscure the true cholera infection burden in an endemic region

临床监测系统掩盖了霍乱流行地区真正的感染负担

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作者:Sonia T Hegde #, Ashraful Islam Khan #, Javier Perez-Saez #, Ishtiakul Islam Khan, Juan Dent Hulse, Md Taufiqul Islam, Zahid Hasan Khan, Shakeel Ahmed, Taner Bertuna, Mamunur Rashid, Rumana Rashid, Md Zakir Hossain, Tahmina Shirin, Kirsten E Wiens, Emily S Gurley, Taufiqur Rahman Bhuiyan, Firdausi Q

Abstract

Our understanding of cholera transmission and burden largely relies on clinic-based surveillance, which can obscure trends, bias burden estimates and limit the impact of targeted cholera-prevention measures. Serological surveillance provides a complementary approach to monitoring infections, although the link between serologically derived infections and medically attended disease incidence-shaped by immunological, behavioral and clinical factors-remains poorly understood. We unravel this cascade in a cholera-endemic Bangladeshi community by integrating clinic-based surveillance, healthcare-seeking and longitudinal serological data through statistical modeling. Combining the serological trajectories with a reconstructed incidence timeline of symptomatic cholera, we estimated an annual Vibrio cholerae O1 infection incidence rate of 535 per 1,000 population (95% credible interval 514-556), with incidence increasing by age group. Clinic-based surveillance alone underestimated the number of infections and reported cases were not consistently correlated with infection timing. Of the infections, 4 in 3,280 resulted in symptoms, only 1 of which was reported through the surveillance system. These results impart insights into cholera transmission dynamics and burden in the epicenter of the seventh cholera pandemic, where >50% of our study population had an annual V. cholerae O1 infection, and emphasize the potential for a biased view of disease burden and infection risk when depending solely on clinical surveillance data.

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