Impact of a multi-pronged cholera intervention in an endemic setting.

Cholera is a bacterial water-borne diarrheal disease transmitted via the fecal-oral route that causes high morbidity in sub-Saharan Africa and Asia. It is preventable with vaccination, and Water, Sanitation, and Hygiene (WASH) improvements. However, the impact of vaccination in endemic settings remains unclear. Cholera is endemic in the city of Kalemie, on the shore of Lake Tanganyika, in the Democratic Republic of Congo, where both seasonal mobility and the lake, a potential environmental reservoir, may promote transmission. Kalemie received a vaccination campaign and WASH improvements in 2013-2016. We assessed the impact of this intervention to inform future control strategies in endemic settings. We fit compartmental models considering seasonal mobility and environmentally-based transmission. We estimated the number of cases the intervention avoided, and the relative contributions of the elements promoting local cholera transmission. We estimated the intervention avoided 5,259 cases (95% credible interval: 1,576.6-11,337.8) over 118 weeks. Transmission did not rely on seasonal mobility and was primarily environmentally-driven. Removing environmental exposure or contamination could control local transmission. Repeated environmental exposure could maintain high population immunity and decrease the impact of vaccination in similar endemic areas. Addressing environmental exposure and contamination should be the primary target of interventions in such settings.