{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T13:15:42Z","timestamp":1758892542301,"version":"3.40.5"},"reference-count":39,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2021,7,8]],"date-time":"2021-07-08T00:00:00Z","timestamp":1625702400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"The Belgian Directorate-General for Development Cooperation"}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Behavioural risk factors for cholera are well established in rural and semi-urban contexts, but not in densely populated mega-cities in Sub-Saharan Africa. In November 2017, a cholera epidemic occurred in Kinshasa, the Democratic Republic of the Congo, where no outbreak had been recorded for nearly a decade. During this outbreak, we investigated context-specific risk factors for cholera in an urban setting among a population that is not frequently exposed to cholera.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methodology\/Principal findings<\/jats:title>\n<jats:p>We recruited 390 participants from three affected health zones of Kinshasa into a 1:1 matched case control study. Cases were identified from cholera treatment centre admission records, while controls were recruited from the vicinity of the cases\u2019 place of residence. We used standardized case report forms for the collection of socio-demographic and behavioural risk factors. We used augmented backward elimination in a conditional logistic regression model to identify risk factors.<\/jats:p>\n<jats:p>The consumption of sachet water was strongly associated with the risk of being a cholera case (p-value 0.019), which increased with increasing frequency of consumption from rarely (OR 2.2, 95% CI 0.9\u20135.2) to often (OR 4.0, 95% CI 1.6\u20139.9) to very often (OR 4.1, 95% CI 1.0\u201316.7). Overall, more than 80% of all participants reported consumption of this type of drinking water. The risk factors funeral attendance and contact with someone suffering from diarrhoea showed a p-value of 0.09 and 0.08, respectively. No socio-demographic characteristics were associated with the risk of cholera.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions\/Significance<\/jats:title>\n<jats:p>Drinking water consumption from sachets, which are sold informally on the streets in most Sub-Saharan African cities, are an overlooked route of infection in urban cholera outbreaks. Outbreak response measures need to acknowledge context-specific risk factors to remain a valuable tool in the efforts to achieve national and regional targets to reduce the burden of cholera in Sub-Saharan Africa.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pntd.0009477","type":"journal-article","created":{"date-parts":[[2021,7,8]],"date-time":"2021-07-08T17:23:16Z","timestamp":1625764996000},"page":"e0009477","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":9,"title":["Sachet water consumption as a risk factor for cholera in urban settings: Findings from a case control study in Kinshasa, Democratic Republic of the Congo during the 2017\u20132018 outbreak"],"prefix":"10.1371","volume":"15","author":[{"given":"Placide","family":"Mbala-Kingebeni","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2686-3149","authenticated-orcid":true,"given":"Florian","family":"Vogt","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6210-5970","authenticated-orcid":true,"given":"Berthe","family":"Miwanda","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tresor","family":"Sundika","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nancy","family":"Mbula","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isaac","family":"Pankwa","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Leopold","family":"Lubula","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6531-0793","authenticated-orcid":true,"given":"Veerle","family":"Vanlerberghe","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alain","family":"Magazani","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mildred Tita","family":"Afoumbom","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jean-Jacques","family":"Muyembe-Tamfum","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2021,7,8]]},"reference":[{"key":"pntd.0009477.ref001","doi-asserted-by":"crossref","first-page":"2099","DOI":"10.3201\/eid1711.111109","article-title":"Cholera\u2014modern pandemic disease of ancient lineage","volume":"17","author":"J Morris","year":"2011","journal-title":"Emerg Infect Dis"},{"key":"pntd.0009477.ref002","doi-asserted-by":"crossref","first-page":"405","DOI":"10.6026\/97320630013405","article-title":"Current views and challenges on clinical cholera","volume":"13","author":"C Somboonwit","year":"2017","journal-title":"Bioinformation"},{"key":"pntd.0009477.ref003","doi-asserted-by":"crossref","first-page":"A13","DOI":"10.1016\/j.vaccine.2019.07.036","article-title":"Cholera surveillance and estimation of burden of cholera","volume":"38","author":"D Ganesan","year":"2020","journal-title":"Vaccine"},{"key":"pntd.0009477.ref004","doi-asserted-by":"crossref","first-page":"e0003832","DOI":"10.1371\/journal.pntd.0003832","article-title":"Updated global burden of cholera in endemic countries","volume":"9","author":"M Ali","year":"2015","journal-title":"PLoS Negl Trop Dis"},{"key":"pntd.0009477.ref005","unstructured":"United Nations Statistics Division. Millennium development goals indicators. https:\/\/millenniumindicators.un.org\/unsd\/mi\/mi_goals.asp (2006). Accessed 13 June 2020."},{"issue":"10133","key":"pntd.0009477.ref006","doi-asserted-by":"crossref","first-page":"1908","DOI":"10.1016\/S0140-6736(17)33050-7","article-title":"Mapping the burden of cholera in sub-saharan africa and implications for control: an analysis of data across geographical scales","volume":"391","author":"J Lessler","year":"2018","journal-title":"Lancet"},{"key":"pntd.0009477.ref007","unstructured":"Global Task Force on Cholera Control. Ending Cholera. A Global Roadmap To 2030 [Accessed 13 June 2020]. Available from: https:\/\/www.who.int\/cholera\/publications\/global-roadmap.pdf?ua=1"},{"key":"pntd.0009477.ref008","doi-asserted-by":"crossref","first-page":"856","DOI":"10.3201\/eid2505.181141","article-title":"Recurrent cholera outbreaks, Democratic Republic Of The Congo, 2008\u20132017","volume":"25","author":"B Ingelbeen","year":"2019","journal-title":"Emerg Infect Dis"},{"journal-title":"Cholera\u2014Kinshasa, Democratic Republic of The Congo, Disease Outbreak News","year":"2018","author":"World Health Organisation","key":"pntd.0009477.ref009"},{"key":"pntd.0009477.ref010","doi-asserted-by":"crossref","first-page":"1151","DOI":"10.1111\/tmi.13293","article-title":"Individual and household exposures associated with cholera transmission in case-control studies: a systematic review","volume":"24","author":"M Phelps","year":"2019","journal-title":"Trop Med Int Health"},{"key":"pntd.0009477.ref011","doi-asserted-by":"crossref","first-page":"S154","DOI":"10.1093\/infdis\/jiy444","article-title":"Individual and household risk factors for symptomatic cholera infection: a systematic review and meta-analysis","volume":"218","author":"A Richterman","year":"2018","journal-title":"J Infect Dis"},{"key":"pntd.0009477.ref012","doi-asserted-by":"crossref","first-page":"1164","DOI":"10.1093\/infdis\/jiy283","article-title":"Micro-hotspots of risk in urban cholera epidemics","volume":"218","author":"A Azman","year":"2018","journal-title":"J Infect Dis"},{"key":"pntd.0009477.ref013","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/s40249-018-0393-8","article-title":"Temporo-spatial dynamics and behavioural patterns of 2012 cholera epidemic in The African mega-city of Conakry, Guinea","volume":"7","author":"A Blake","year":"2018","journal-title":"Infect Dis Poverty"},{"key":"pntd.0009477.ref014","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1093\/trstmh\/tru194","article-title":"Climate change, urbanization and disease: summer in the city","volume":"109","author":"R Reiner","year":"2014","journal-title":"Trans R Soc Trop Med Hyg"},{"key":"pntd.0009477.ref015","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1186\/2049-9957-3-37","article-title":"Interaction between climatic, environmental, and demographic factors on cholera outbreaks in Kenya","volume":"3","author":"J Stoltzfus","year":"2014","journal-title":"Infect Dis Poverty"},{"key":"pntd.0009477.ref016","doi-asserted-by":"crossref","first-page":"S86","DOI":"10.1093\/infdis\/jit204","article-title":"Elimination of cholera in the Democratic Republic of The Congo: the new national policy","volume":"208","author":"J Muyembe","year":"2013","journal-title":"J Infect Dis"},{"key":"pntd.0009477.ref017","unstructured":"R\u00e9publique D\u00e9mocratique Du Congo, Minist\u00e8re Du Plan. Plan Strat\u00e9gique Multisectoriel d\u2019Elimination Du Chol\u00e9ra En R\u00e9publique D\u00e9mocratique Du Congo 2018\u20132022 [Accessed 13 June 2020]. Available from: https:\/\/www.plateformecholera.info\/attachments\/article\/554\/PMSEC%202018_2022_30032018.pdf"},{"key":"pntd.0009477.ref018","unstructured":"R\u00e9publique D\u00e9mocratique Du Congo, Minist\u00e8re De La Sante Publique. Plan Strat\u00e9gique Multisectoriel d\u2019Elimination Du Chol\u00e9ra En R\u00e9publique D\u00e9mocratique Du Congo 2013\u20132017 [Accessed 13 June 2020]. Available from: http:\/\/plateformecholera.info\/attachments\/article\/460\/PLAN%20ELIMINATION%20CHOLERA%202013%202017%20F%C3%A9v28fev.pdf"},{"key":"pntd.0009477.ref019","unstructured":"R\u00e9publique D\u00e9mocratique Du Congo, Minist\u00e8re De La Sante Publique. Guide Technique Pour La Surveillance Int\u00e9gr\u00e9e De La Maladie Et Riposte [Accessed 13 June 2020]. Available from: https:\/\/docplayer.fr\/20933821-Republique-democratique-du-congo-ministere-de-la-sante-publique-secretariat-general-a-la-sante-direction-de-lutte-contre-la-maladie.html"},{"key":"pntd.0009477.ref020","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1007\/BF02294361","article-title":"Model selection and Akaike\u2019s Information Criterion (AIC): the general theory and its analytical extensions","volume":"52","author":"H Bozdogan","year":"1987","journal-title":"Psychometrika"},{"key":"pntd.0009477.ref021","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1002\/bimj.201700067","article-title":"Variable Selection\u2014a review and recommendations for the practicing statistician","volume":"60","author":"G Heinze","year":"2018","journal-title":"Biom J."},{"key":"pntd.0009477.ref022","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1093\/aje\/kwp425","article-title":"Multiple imputation for missing data: fully conditional specification versus multivariate normal imputation","volume":"171","author":"K Lee","year":"2010","journal-title":"Am J Epidemiol"},{"key":"pntd.0009477.ref023","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1002\/pst.1549","article-title":"Missing data in clinical trials: from clinical assumptions to statistical analysis using pattern mixture models","volume":"12","author":"B Ratitch","year":"2013","journal-title":"Pharm Stat."},{"key":"pntd.0009477.ref024","doi-asserted-by":"crossref","first-page":"115","DOI":"10.4236\/ojmm.2012.23017","article-title":"Microbiological examination of sachet water due to a cholera outbreak in Ibadan, Nigeria","volume":"2","author":"F Oluwafemi","year":"2012","journal-title":"Open J Med Microbiol"},{"key":"pntd.0009477.ref025","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/j.healthplace.2011.09.020","article-title":"When urban taps run dry: sachet water consumption and health effects in low income neighborhoods of Accra, Ghana","volume":"18","author":"J Stoler","year":"2012","journal-title":"Health Place"},{"key":"pntd.0009477.ref026","doi-asserted-by":"crossref","first-page":"303","DOI":"10.3390\/ijerph13030303","article-title":"Effects of sachet water consumption on exposure to microbe-contaminated drinking water: household survey evidence from Ghana","volume":"13","author":"J Wright","year":"2016","journal-title":"Int J Environ Res Public Health"},{"key":"pntd.0009477.ref027","doi-asserted-by":"crossref","first-page":"526","DOI":"10.4269\/ajtmh.17-0804","article-title":"An evolving choice in a diverse water market: a quality comparison of sachet water with community and household water sources in Ghana","volume":"99","author":"D Guzm\u00e1n","year":"2018","journal-title":"Am J Trop Med Hyg"},{"key":"pntd.0009477.ref028","doi-asserted-by":"crossref","first-page":"e0131772","DOI":"10.1371\/journal.pone.0131772","article-title":"Microbiological and chemical quality of packaged sachet water and household stored drinking water in Freetown, Sierra Leone","volume":"10","author":"MB Fisher","year":"2015","journal-title":"PLoS One"},{"key":"pntd.0009477.ref029","doi-asserted-by":"crossref","first-page":"800","DOI":"10.3390\/w11040800","article-title":"Informally vended sachet water: handling practices and microbial water quality","volume":"11","author":"D Manjaya","year":"2019","journal-title":"Water"},{"key":"pntd.0009477.ref030","unstructured":"Dzotsi E, Asamoah A, Noor C, Gershon A, Yirenchi E, Nuoh R, et al. Report of cholera outbreak investigation, Greater Accra Region, June-August 2014 [Accessed 13 June 2020]. Available from: https:\/\/ghana.um.dk\/en\/news\/newsdisplaypage\/\/~\/media\/ghana\/documents\/cholera%20outbreak%20investigation%20report%20gar%20final_12082014.pdf"},{"issue":"19","key":"pntd.0009477.ref031","doi-asserted-by":"crossref","first-page":"560","DOI":"10.15585\/mmwr.mm6719a6","article-title":"Notes from the Field: Outbreak of Vibrio cholerae Associated with Attending a Funeral\u2014Chegutu District, Zimbabwe","volume":"67","author":"JB McAteer","year":"2018","journal-title":"MMWR Morb Mortal Wkly Rep"},{"issue":"1","key":"pntd.0009477.ref032","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1017\/S0950268897008170","article-title":"Funerals during the 1994 cholera epidemic in Guinea-Bissau, West Africa: the need for disinfection of bodies of persons dying of cholera","volume":"120","author":"G Gunnlaugsson","year":"1998","journal-title":"Epidemiol Infect"},{"key":"pntd.0009477.ref033","doi-asserted-by":"crossref","first-page":"1128","DOI":"10.1186\/s12889-015-2485-8","article-title":"Assessing the risk factors of cholera epidemic in The Buea Health District Of Cameroon","volume":"15","author":"D Nsagha","year":"2015","journal-title":"BMC Public Health"},{"key":"pntd.0009477.ref034","unstructured":"Global Task Force on Cholera Control. Cholera Outbreak Response Manual, Section 7: Case Management in Treatment Facilities [Accessed 27 April 2021]. Available from: https:\/\/choleraoutbreak.org\/book-page\/section-7-case-management-treatment-facilities."},{"key":"pntd.0009477.ref035","doi-asserted-by":"crossref","first-page":"074029","DOI":"10.1088\/1748-9326\/aa751f","article-title":"Estimation of packaged water consumption and associated plastic waste production from household budget surveys","volume":"12","author":"N Wardrop","year":"2017","journal-title":"Environ Res Lett"},{"key":"pntd.0009477.ref036","doi-asserted-by":"crossref","first-page":"369","DOI":"10.2166\/washdev.2017.155","article-title":"The role of packaged water in meeting global targets on improved water access","volume":"7","author":"S Vedachalam","year":"2017","journal-title":"J Water Sanit Hyg Dev"},{"key":"pntd.0009477.ref037","doi-asserted-by":"crossref","first-page":"S137","DOI":"10.1093\/infdis\/jiy486","article-title":"Global cholera epidemiology: opportunities to reduce the burden of cholera by 2030","volume":"218","author":"D Legros","year":"2018","journal-title":"J Infect Dis"},{"key":"pntd.0009477.ref038","doi-asserted-by":"crossref","first-page":"A132","DOI":"10.1016\/j.vaccine.2019.08.086","article-title":"Global oral cholera vaccine use, 2013\u20132018","volume":"38","author":"L Pezzoli","year":"2020","journal-title":"Vaccine"},{"key":"pntd.0009477.ref039","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1080\/21645515.2016.1245250","article-title":"Achievements and challenges for the use of killed oral cholera vaccines in the global stockpile era","volume":"13","author":"SN Desai","year":"2017","journal-title":"Hum Vaccin Immunother"}],"container-title":["PLOS Neglected Tropical Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0009477","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,7,8]],"date-time":"2021-07-08T17:23:49Z","timestamp":1625765029000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0009477"}},"subtitle":[],"editor":[{"given":"Jeffrey H.","family":"Withey","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2021,7,8]]},"references-count":39,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2021,7,8]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pntd.0009477","relation":{},"ISSN":["1935-2735"],"issn-type":[{"type":"electronic","value":"1935-2735"}],"subject":[],"published":{"date-parts":[[2021,7,8]]}}}