Impact of Patron Saint Festivities on Cholera in Three Communes in Haiti

Impact of Patron Saint Festivities on Cholera in Three Communes in Haiti | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Impact of Patron Saint Festivities on Cholera in Three Communes in Haiti Kenny Moise, Aude Mélody Achille, Doudou Batumbo, Bertiny Bourdeau, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-28562/v4 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2020 Read the published version in BMC Public Health → Version 4 posted 2 You are reading this latest preprint version Show more versions Abstract Introduction: Religious pilgrimages are among the anthropogenic factors known to be associated with the transmission of diarrheal diseases, such as cholera. This ecological study aimed to describe the evolution of cholera and assess the relationship between the implementation of the ‘coup de poing’ strategy during the patron saint festivities and the incidence of cholera in the three communes of Cabaret, Carrefour, and Croix-des-Bouquets in Haiti in 2017. Materials/Methods: An epidemiological curve was produced to illustrate the evolution of cholera at the communal level. Generalized linear models assuming a Poisson distribution were used to weight the annual cholera incidence of communal sections against variables such as the number of patronal festivities, population density and annual precipitation rates. The number of cases in the week of the festivity as well as one and two weeks later was weighted against patronal festivities and weekly precipitation rates. Results: In total, 3 633 suspected cholera cases were continuously reported in three communes in Haiti (Cabaret, Carrefour, Croix-des-bouquets) during the 52-epidemiological week period in 2017. After controlling for rainfall and population density, the implementation of the ‘coup de poing’ strategy during the patron saint festivities was associated with a significant reduction in cholera incidence of 57.23% [PR=0.4277 (97.5% CI: 0.2798-0.6193), p=0.0000244]. The implementation of the strategy was associated with a reduction in cholera incidence of 25.41% one week following patronal festivities. Conclusion: This study showed a continuous presence of cholera in three communes in Haiti in 2017 and an association between the implementation of the ‘coup de poing’ strategy during patronal festivities and a reduction in cholera incidence. The findings imply that the multi-partner ‘coup de poing’ strategy may have contributed to the reduced cholera incidence following patron saint festivities and in Ouest department in Haiti in 2017. Health Policy Infectious Diseases Cholera Patronal festivities Mass gatherings Haiti Figures Figure 1 Figure 2 Background During a cholera epidemic, the human-to-human transmission such as that noted in large gatherings, without involving the aquatic environment becomes the most important route of transmission 1, 2 . In Haiti, the celebration of local patron saints represents a highlight of cultural and religious life and involves large movements of thousands of pilgrims at fixed periods over the year. In 2014, the mishandling of a patron saint festivity in the Artibonite department was cited as the potential cause of an outbreak that spread to the rest of the country 3 . Since the incidence of cholera in 2016 was increased at the national level compared with incidence rates in 2014, six communes, including Cabaret, Carrefour and Croix des-Bouquets, have been identified by the Department of Epidemiology, Laboratories and Research (DELR) as contributors to recurrent outbreaks in the remainder of the country at key time periods, such as periods of time following patron saint festivities 4 . A multi-partner “coup de poing” strategy has been launched in July 2017 to respond to the cholera epidemic in the Ouest department, mainly in these communes in order to reinforce the alert-response strategy upstream of mass gathering events such as patronal festivities 5 . Under the leadership of the Ministry of Health and the National Directorate of Drinking Water and Sanitation (French acronym DINEPA), it entailed reinforced epidemiologic surveillance, investigations, institutional management, community response and communication. During the operation, 26 mobile teams have been deployed among which 10 response teams and 16 community outreach teams in charge of door-by-door awareness and follow-up on interventions. As of November 2017, the teams responded to 1 102 alerts. In total, 8 929 sanitary kits and 644 123 oral rehydration solutions were distributed, 14 058 water point decontaminations conducted, 69 chlorination points and 17 hand washing points installed, 78 mass awareness sessions organized in marketplaces, churches and schools, and 10 744 flyers containing awareness messages distributed reaching 1 110 individuals. However, vaccination was not involved in the intervention package. Although an oral cholera vaccine (OCV) coverage was not determined for each communal section prior to the intervention, the Ouest department showed a 44% of two-dose coverage in 2014 6 . Previous OVC campaigns in Haiti were limited. A pilot project was conducted in a rural area in the Artibonite department in 2012, followed by targeted campaigns in specific communes in the North in 2013, South in 2016 and Centre department in 2013 and 2017 7, 8, 9 . As of the 32 nd epidemiological week of 2020, no reported cases have been biologically confirmed since the 4 th week of 2019 10 . However, the long-term phase of the 10-year plan to eliminate cholera has been launched in 2019 with an emphasis on access to clean water and sanitation. This study aimed to describe the evolution of cholera and assess the relationship between the implementation of the ‘coup de poing’ strategy during the patron saint festivities and the incidence of cholera in the three communes of Cabaret, Carrefour, and Croix-des-Bouquets in 2017. Methods Data source. A cholera case was defined as any patient presenting to a health facility after developing acute diarrhoeal disease with or without vomiting 4 . Cases of cholera during the period from January 1 st , 2017, to December 31 st , 2017, were obtained from the electronic databases maintained by the Ouest departmental health direction, which is updated weekly from the paper registry used by the clinical staff of the Cholera Treatment Centers. The number and date of occurrence of patron saint holidays per communal section over the period were collected from an online registry of the Ministry of Agriculture, Natural Resources and Rural Development (MANRRD) (Table 1), and the Catholic Church calendar 11 . We collected population counts and density data from the Haitian Informatics and Statistics Institute (HISI) and daily precipitation data from the National Aeronautics and Space Administration (NASA) Giovanni data analysis system 12, 13 . The components and activities of the “coup de poing” strategy were retrieved from an unpublished report of DINEPA of the ‘coup de poing’ operation (Table 2). Data analysis. For spatial analysis, we examined the number of patronal festivities, annual case count, population count, population density and annual precipitation rates per communal section. Incidences per 100 inhabitants were calculated by dividing the case counts by population size. The data were imported in R® software (version 3.6.0. The R Foundation for Statistical Computing. April 26, 2019). Using a generalized linear model (glm) and assuming a Poisson distribution, we weighted the annual cholera incidence against the number of festivities per communal section, annual precipitation rate and population density. Since the ‘coup de poing’ data were collected at the communal level, while our analysis was conducted at a finer scale, we used the patronal festivities as a proxy to assess the relationship between the implementation of the strategy and cholera incidence. The following formula was used: glm (formula = Incidence ~ Festivity + Density + Rain + (1|section) + (1|commune), family = Poisson, data = data) For temporal analysis, we distributed the number of patronal festivities, weekly precipitation rate and case count per epidemiological week (W0). Case counts in communal sections were also distributed for the 2 subsequent weeks (W1 and W2, respectively). A glm was used to assess the weight of case count at W0, W1 and W2 against number of patronal festivities and weekly precipitation rates. The following formulas were used: glm (formula = Case.W0 ~ Festivity + Rain + (1|section) + (1|commune), family = Poisson, data = data1) glm (formula = Case.W1 ~ Festivity + Rain + (1|section) + (1|commune), family = Poisson, data = data1) glm (formula = Case.W2 ~ Festivity + Rain + (1|section) + (1|commune), family = Poisson, data = data1) For the final analysis, we combined the data of the three communes on the basis that they have similar characteristics in terms of type of land, presence of rivers and main roads and having been identified by the DELR as cholera-persistent communes (Figure 1). Results In 2017, Haiti reported a total of 13 681 cases of cholera to the World Health Organization among which 3 633 suspected cholera cases were recorded in Cabaret, Carrefour and Croix-des-Bouquets 14 . The attack rates were 211.44, 17.31 and 52.28 per 10 000 inhabitants respectively. The epidemiological curve shows a persistence of cholera throughout the year, with all three communes having reported cases during all 52 epidemiological weeks of 2017, and noteworthy peaks at the 8 th , 18 th and 19 th epidemiological weeks (Figure 2). After controlling for rainfall and population density, the implementation of the ‘coup de poing’ strategy during the patron saint festivities was associated with a significant reduction in annual cholera incidence of 57.23% [PR=0.4277 (97.5% CI: 0.2798-0.6193), p=0.0000244] in communal sections of the three communes combined. At W0, precipitation rate [PR= 1.0000 (97.5% CI: 0.9994- 1.0007), p= 0.828] and the implementation of the ‘coup de poing strategy’ during patronal festivities [PR= 0.9638 (97.5% CI: 0.7903- 1.1617), p= 0.707] were not associated with cholera incidence. At W1, the implementation of the ‘coup de poing’ strategy during patronal festivities [PR= 0.7458 (97.5% CI: 0.5943-0.9217), p= 0.0087] was significantly associated with a reduction in cholera incidence of 25.41% in communal sections of the three communes combined, after controlling for rainfall [PR= 1.0022 (97.5% CI: 1.0016-1.0028), p= 0.00000000000127]. At W2, precipitation rate [PR= 1.0030 (97.5% CI: 0.8589- 1.2504), p= 0.002*10 -13 ] and the implementation of the ‘coup de poing’ strategy during patronal festivities [PR= 1.0420 (97.5% CI: 1.0024- 1.0036), p= 0.667] were not associated with cholera incidence (Table 3). Discussion Studies and reports have pointed out the relationship between religious pilgrimages and cholera outbreaks, such as the outbreak in Senegal between 2004 and 2006 15, 16 . In a previous study in 2014, Gazin observed a sudden increase in the number of cholera cases in Saint-Michel de l'Attalaye, in Haiti’s Artibonite department, at approximately the same time as the local patron saint festival in a nearby locality, one year after the launch of the National Plan for the Elimination of Cholera in Haiti 3 . Cholera travels with humans. On the other hand, environmental factors such as high population density and rainy seasons are known risk factors for increased cholera incidence in the Democratic Republic of Congo and other African countries 17, 18 . However, our study showed that the incidence of cholera decreases significantly a week after patronal festivities in communes of Cabaret, Carrefour and Croix-des-bouquets. This finding suggests that the “coup de poing” strategy, which was deployed upstream of mass gatherings, may have contributed in mitigating the risk of cholera outbreaks in 2017. Lorraine Williams et al. studied the role of perceived risk in reducing cholera vulnerability in Mozambique, depicting it as a motivator in risk management approaches 19 . As they emphasized, periods perceived to be of greater risk for cholera transmission were associated with increased vigilance and risk reduction measures. Based on the experience from the outbreak described by Gazin, the concept of perceived risk might play a role in our observations, amplified by the important number of awareness initiatives conducted and individuals reached during the “coup de poing” strategy; however, more research is needed to assess the perception of risk towards infectious diseases among rural populations in Haiti during periods of patronal festivities. Furthermore, we also assessed the prevention and response strategy in relation to cholera outbreaks in Haiti. In the context of the elimination plan, a case-area targeted rapid response strategy, that was first implemented in 2013, involves the Haitian Ministry of Health, DINEPA and international partners such as Pan-American Health Organization and United Nations Children’s Fund. 20 . Various preventive and alert-response measures were thoroughly deployed from the launch in 2017 to respond to cholera alerts in a timely fashion. Patronal festivities in communal sections are occasions for which the alert-response system should be intensified in order to treat cases and prevent outbreaks. Community outreach and educational activities in areas near cases were used to reinforce the management of cases. An estimation of the effectiveness of such case-area targeted interventions in the Center department between 2015 and 2017 has shown positive outcomes in order to mitigate and shorten cholera outbreaks 21 . Regarding rainfall and population density, in our study they did not influence the annual incidence of cholera or the incidence one week following patronal festivities. However, studies have previously shown a significant association between seasonal rainfall and cholera 22 . Hurricane Matthew, which landed in Haiti in October 2016, was followed by increased number of reported cholera cases 23 . Marisa et al. also showed that increased cholera incidence was associated with cumulative precipitation greater than 30 mm 4-7 days before infections were reported 24 . However, in the context of patronal festivities, not all communal sections experienced high rates of precipitation in the week preceding the gathering events, as the events were not all held in rainy seasons, the mean rate of precipitation being 38.78 mm. A study has identified a link between cholera and social factors such as population density in vulnerable areas 25 . Nonetheless, communal sections in Haiti are largely unurbanized, therefore the incidence of cholera might be associated with different factors such as the practice of latrine sharing 26 . Limitations and perspectives Limitations of this study are attributable to the quality of the data recorded in the source databases and then entered into our database, specifically with regard to the origin of the patients. The origin of the patients was not recorded in all cases. In addition, the population densities of the communal sections used in this analysis are dated to 2015, based on the latest HISI estimates. These data may not reflect the current situation in the communal sections. Furthermore, as there is no national registry of interventions, data regarding cholera interventions prior to the ‘coup de poing’ strategy could not be integrated in the model. Based on our findings, further investigations should emphasize the impact of interventions following patronal festivities on cholera incidence. We attempted to control for failure of the surveillance system during the study period using the surveillance completion data. However, this data is only collected at the departmental level (first administrative level) and could not be integrated in our model. It is likely that our observations might be due to decreased cholera case reporting from the cholera treatment centers and decreased health care attendance as health care workers and patients focus on the festivities. We also were not able to assess the relationship with particular interventions of the ‘coup de poing’ strategy since data were collected at the communal level. However, the patronal festivities are the best proxy to the extent of our knowledge. This emphasizes the need to collect intervention data systematically at all administrative levels. Our study being inaugural, it opens doors to further investigations of spatial and temporal dynamics of cholera in regards to preventive interventions. Conclusion Sociocultural factors contribute to the human-to-human transmission of cholera. In 2017, the cholera epidemic showed a persistent pattern in three communes in the Ouest department in Haiti. In this study, our model revealed a statistically significant association between the implementation of the ‘coup de poing’ strategy during patronal festivities and a reduction in cholera incidence. The findings in this study suggest that that the multi-partner ‘coup de poing’ strategy may have contributed to the reduced cholera incidence during patron saint festivities and in Ouest department in Haiti 2017. Abbreviations DELR: Department of Epidemiology, Laboratories and Research; DINEPA: Direction National d’Eau Potable et d’Assainissement; GLM: Generalized Linear Model; HISI: Haitian Informatics and Statistics Institute; MANRRD: Ministry of Agriculture, Natural Resources and Rural Development; NASA: National Aeronautics and Space Administration. Declarations Ethics approval and consent to participate Ethical approval was granted by the Ethical Review Committee of Haiti’s Ministry of Health. Databases were anonymized to ensure confidentiality. Consent for publication The authors consent to Editorial Board of the journal BMC to publish the paper. The author accepts responsibility for publishing this material in his own name, as well as on behalf of all co- authors. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The Ouest departmental health direction database is close to public access. We obtained administrative permission to access and use it for this study. The MANRRD ( http://agriculture.gouv.ht/statistiques_agricoles/EnqueteCommunautaire/documents/DEP05.html .), HISI ( https://web.archive.org/web/20151106110552/http://www.ihsi.ht/pdf/projection/Estimat_PopTotal_18ans_Menag2015.pdf ) and NASA ( https://giovanni.gsfc.nasa.gov/giovanni/ ) data are available online and public access is open. Competing interests Authors declare that they have no competing interests. Funding The authors did not receive funding for this study. Author’s contributions KM and AMA conceived the idea. KM and BB collected data. KM, AMA and DB did the analysis and interpretation of data. KM wrote the manuscript. AMA, DB, BB, SR, GL, JHH and CR reviewed the manuscript and made intellectual input. All authors read and approved the final manuscript. 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Patron Saint Festivities at communal sections level in 3 communes in Haiti Communes Communal sections Patron saints Date of occurrence Cabaret 1 ère section Boucassin Saint Agnès July 16 Cabaret 2 ème section Boucassin Mont Carmel July 16 Cabaret 2 ème section Boucassin Saint Joseph March 19 Cabaret 3 ème section Source Matelas Saint Gérard October 6 Cabaret 4 ème section Fonds des Blancs Saint Michel September 29 Croix-des-Bouquets 1 ère section Varreux Sainte Thérèse October 1 Croix-des-Bouquets 2 ème section Varreux Marie Madeleine July 22 Croix-des-Bouquets 2 ème section Varreux Michel-Ange September 30 Croix-des-Bouquets 3 ème section Petit Bois Saint Antoine June 3 Croix-des-Bouquets 4 ème section Petit Bois Notre Dame du Rosaire June 24 Croix-des-Bouquets 4 ème section Petit Bois Notre-Dame du Perpétuel Secours October 7 Croix-des-Bouquets 5 ème section Petit Bois Notre Dame de Lamercie September 24 Croix-des-Bouquets 6 ème section Belle Fontaine Notre Dame Deslourdes February 11 Croix-des-Bouquets 9 ème section Crochus Sainte Marie joseph February 4 Croix-des-Bouquets 10 ème section des Orangers Sainte Geneviève January 3 Croix-des-Bouquets 10 ème section des Orangers Sainte Thérèse de l’Enfant Jésus October 3 Carrefour 3 ème section Taïfer Sainte Croix September 14 Carrefour 7 ème section Lavalle Saint Joseph March 19 Carrefour 7 ème section Lavalle Sainte Thérèse de l’Enfant Jésus October 1 Carrefour 9 ème section Bizoton Mont Carmel July 16 Carrefour 10 ème section Thor Saint Charles November 4 Carrefour 10 ème section Thor Notre-Dame du Perpétuel Secours June 27 Carrefour 11 ème section Rivière Froide Sainte-Thérèse de l'Enfant Jésus October 1 Source: Ministry of Agriculture, Natural Resources and Rural Development, 2008. Community survey, Definitive results. http://agriculture.gouv.ht/statistiques_agricoles/EnqueteCommunautaire/documents/DEP05.html. Published online in 2008. Accessed on January 24, 2019 Table 2. Components and activities of the ‘coup de poing’ strategy deployed in the Ouest department in Haiti, 2017 Components Activities Coordination § 55 situation room meetings Epidemiologic surveillance § Daily action-oriented epidemiologic analysis Investigation § More than 7 multisectoral and multi-partnered investigations Care delivery § 30 supervision visits of Diarrheal Treatment Centers § 10 follow-up visits § Training of 20 nurses, 7 nursing assistants and 10 hygienists § Installation and rehabilitation of equipment on 3 outbreak sites by partner NGOs § Supply of treatment centers with materials and establishment of a contingency stock § Transport of specimen to the National public health laboratory by partner NGOs Community response and water, sanitation and hygiene § Deployment of 26 mobile teams § Distribution of 8 929 sanitary kits § Distribution of 644 123 oral rehydration solutions § Operation of 14 058 water point decontaminations § Installation of 69 chlorination points § Installation of 17 hand washing points § Organization of 78 mass awareness sessions in marketplaces, churches and schools § Distribution of 10 744 flyers containing awareness messages Communication § Training of 401 focal points in local town halls § Training of 108 marketplace directors, 155 grassroot organizations directors and 136 funeral directors § 43 street theater performances reaching 4 200 individuals § 30 public transportation debates reaching 7 350 individuals § Distribution of T-shirts and USB with awareness messages reaching 9 600 individuals § 6 workshops targeting 210 religious leaders § Involvement of 85 churches reaching 17 000 individuals Source: DINEPA, 2017. [Report] Results of the ‘coup de poing’ strategy against cholera, Ouest department, Haiti. Table 3. Model parameters and Prevalence Ratios of the Generalized Linear Model selected for cholera cases following patronal festivities at W0, W1 and W2 in communal sections, Haiti, 2017* Characteristic Coefficient estimate Standard error Z value Pr(>|t|) Prevalence Ratio CI (2.5-97.5) % Intercept 2017 -55.93 30.60 -1.83 0.07 5.11*10 -25 2.40*10 -52 - 3.86 Patronal festivities in 2017 -8.49*10 -1 2.01*10 -1 -4.22 2.44*10 -5 *** 0.43 2.80*10 -1 - 0.62 Density in 2017 -2.09*10 -4 3.37*10 -5 -6.20 5.83*10 -10 *** 1.00 10.00*10 -1 - 1. 00 Precipitations in 2017 2.97*10 -2 1.52*10 -2 1.95 0.05 1.03 1.00 - 1.06 Intercept W0 1.11 0.02 64.27 <2*10 -16 *** 4.10 3.93 – 4.28 Patronal festivities at W0 -0.04 0.10 -0.38 0.71 0.96 0.79 - 1.16 Precipitations at W0 0.78*10 -5 3.60*10 -4 0.21 0.83 1.00 1.00 - 1.00 Intercept W1 1.33 0.02 60.19 <2*10 -16 *** 3.79 3.63 - 3.96 Patronal festivities at W1 -0.29 0.11 -2.62 1.871*10 -2 ** 0.75 0.59 - 0.92 Precipitations at W1 0.02*10 -1 0.03*10 -2 7.10 1.27e-12 *** 1.00 1.00 - 1.00 Intercept W2 1.30 0.02 57.46 <2*10 -16 *** 3.65 3.50 - 3.82 Patronal festivities at W2 0.04 0.10 0.43 0.67 1.04 0.86 - 1.25 Precipitationss at W2 0.03*10 -1 0.31*10 -3 9.74 |t|), probability of the null hypothesis of a coefficient estimate not statistically different from zero ; CI, confidence interval; intercept, average number of cases. Cite Share Download PDF Status: Published Journal Publication published 01 Oct, 2020 Read the published version in BMC Public Health → Version 4 posted Submission checks completed at journal 23 Sep, 2020 Editorial decision: Accept 23 Sep, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-28562","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":2687992,"identity":"5ad39aad-aeb3-4695-8cff-fee0eaf20164","order_by":0,"name":"Kenny Moise","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYBACCSjNw8DAfADElyFFC1sCiM9DtBaQLgOoXgJAsr332GPeHBsZ+faez69u1FjwMLAfProBnxZpnnPpxrzb0ngMzpzdZp1zDOgwnrS0G/i0yEnkmEnzbjvMYyCRu804hw2oRYLHDL8W+TcQLfLz3zwzzvlHhBZpoAKwFoYbPMyPc9uI0CLZk2MmORfslzQz5tw+CR42Qn6ROH7GTOLtNht7+fbDjz/nfKuT42c/fAyvFhBggsYFGziS2AgpBwHGHxCa+QMxqkfBKBgFo2DkAQA5ET9odS7HOwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-2776-6615","institution":"Universite Quisqueya","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kenny","middleName":"","lastName":"Moise","suffix":""},{"id":2687993,"identity":"19e28eca-af5d-4a3e-993a-581cfdc7469f","order_by":1,"name":"Aude Mélody Achille","email":"","orcid":"","institution":"Universite Quisqueya","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aude","middleName":"Mélody","lastName":"Achille","suffix":""},{"id":2687994,"identity":"ce9ddf03-d1d0-41e7-95d3-a98b3fd3cbdf","order_by":2,"name":"Doudou Batumbo","email":"","orcid":"","institution":"Universite de Kinshasa","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Doudou","middleName":"","lastName":"Batumbo","suffix":""},{"id":2687995,"identity":"3491fb34-ed02-436c-b8ba-b573921b3a6a","order_by":3,"name":"Bertiny Bourdeau","email":"","orcid":"","institution":"Universite Quisqueya","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bertiny","middleName":"","lastName":"Bourdeau","suffix":""},{"id":2687996,"identity":"a15371d1-6ee3-40d3-9b05-eb7dff28807a","order_by":4,"name":"Stanislas Rebaudet","email":"","orcid":"","institution":"Assistance Publique Hopitaux de Marseille","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stanislas","middleName":"","lastName":"Rebaudet","suffix":""},{"id":2687997,"identity":"df6c2f6b-9642-4fff-be68-12a8e96c544f","order_by":5,"name":"Gérald Lerebours","email":"","orcid":"","institution":"Universite Quisqueya","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gérald","middleName":"","lastName":"Lerebours","suffix":""},{"id":2687998,"identity":"e4e3041a-0323-4438-85ae-5907051b6c11","order_by":6,"name":"Jean Hugues Henrys","email":"","orcid":"","institution":"Universite Quisqueya","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Hugues","lastName":"Henrys","suffix":""},{"id":2687999,"identity":"caf96536-f12e-4e57-99bc-ec9632ab5537","order_by":7,"name":"Christian Raccurt","email":"","orcid":"","institution":"Universite Quisqueya","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Raccurt","suffix":""}],"badges":[],"createdAt":"2020-05-11 11:34:44","currentVersionCode":4,"declarations":"","doi":"10.21203/rs.3.rs-28562/v4","doiUrl":"https://doi.org/10.21203/rs.3.rs-28562/v4","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-020-09601-9","type":"published","date":"2020-10-01T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2568544,"identity":"cc391a3c-12b6-4b41-9882-289ad4d61e36","added_by":"auto","created_at":"2020-09-24 01:14:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":102268,"visible":true,"origin":"","legend":"Geographic location of Cabaret, Carrefour and Croix-des-bouquets in regards to main roads and presence of rivers. Data source: National Center for Geospatial Information, 2017. Available online www.haitidata.org ","description":"","filename":"ScreenShot20200918at11.27.16AM.png","url":"https://assets-eu.researchsquare.com/files/rs-28562/v4/ScreenShot20200918at11.27.16AM.png"},{"id":2568545,"identity":"de05737a-c697-4d31-a190-df687a99a933","added_by":"auto","created_at":"2020-09-24 01:14:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":82374,"visible":true,"origin":"","legend":"Evolution of cholera in Cabaret, Carrefour and Croix-des-Bouquets in Haiti per epidemiological week in 2017. Number of cholera cases in Cabaret, Carrefour and Croix-des-bouquets and precipitation rates per epidemiological week in mm in 2017. ","description":"","filename":"ScreenShot20200918at11.27.26AM.png","url":"https://assets-eu.researchsquare.com/files/rs-28562/v4/ScreenShot20200918at11.27.26AM.png"},{"id":13596324,"identity":"876bbc05-3d2c-49f6-a7fa-0b98d39c4179","added_by":"auto","created_at":"2021-09-17 05:27:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":377559,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-28562/v4/97876645-b7c1-4a77-a478-8010e112df59.pdf"}],"financialInterests":"","formattedTitle":"Impact of Patron Saint Festivities on Cholera in Three Communes in Haiti","fulltext":[{"header":"Background","content":"\u003cp\u003eDuring a cholera epidemic, the human-to-human transmission such as that noted in large gatherings, without involving the aquatic environment becomes the most important route of transmission \u003csup\u003e1, 2\u003c/sup\u003e. In Haiti, the celebration of local patron saints represents a highlight of cultural and religious life and involves large movements of thousands of pilgrims at fixed periods over the year. In 2014, the mishandling of a patron saint festivity in the Artibonite department was cited as the potential cause of an outbreak that spread to the rest of the country \u003csup\u003e3\u003c/sup\u003e. Since the incidence of cholera in 2016 was increased at the national level compared with incidence rates in 2014, six communes, including Cabaret, Carrefour and Croix des-Bouquets, have been identified by the Department of Epidemiology, Laboratories and Research (DELR) as contributors to recurrent outbreaks in the remainder of the country at key time periods, such as periods of time following patron saint festivities \u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eA multi-partner \u0026ldquo;coup de poing\u0026rdquo; strategy has been launched in July 2017 to respond to the cholera epidemic in the Ouest department, mainly in these communes in order to reinforce the alert-response strategy upstream of mass gathering events such as patronal festivities \u003cstrong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/strong\u003e. Under the leadership of the Ministry of Health and the National Directorate of Drinking Water and Sanitation (French acronym DINEPA), it entailed reinforced epidemiologic surveillance, investigations, institutional management, community response and communication.\u003c/p\u003e\n\u003cp\u003eDuring the operation, 26 mobile teams have been deployed among which 10 response teams and 16 community outreach teams in charge of door-by-door awareness and follow-up on interventions. As of November 2017, the teams responded to 1 102 alerts. In total, 8 929 sanitary kits and 644 123 oral rehydration solutions were distributed, 14 058 water point decontaminations conducted, 69 chlorination points and 17 hand washing points installed, 78 mass awareness sessions organized in marketplaces, churches and schools, and 10 744 flyers containing awareness messages distributed reaching 1 110 individuals. However, vaccination was not involved in the intervention package. Although an oral cholera vaccine (OCV) coverage was not determined for each communal section prior to the intervention, the Ouest department showed a 44% of two-dose coverage in 2014 \u003cstrong\u003e\u003csup\u003e6\u003c/sup\u003e\u003c/strong\u003e.\u0026nbsp; Previous OVC campaigns in Haiti were limited. A pilot project was conducted in a rural area in the Artibonite department in 2012, followed by targeted campaigns in specific communes in the North in 2013, South in 2016 and Centre department in 2013 and 2017 \u003cstrong\u003e\u003csup\u003e7, 8, 9\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eAs of the 32\u003csup\u003end\u003c/sup\u003e epidemiological week of 2020, no reported cases have been biologically confirmed since the 4\u003csup\u003eth\u003c/sup\u003e week of 2019 \u003csup\u003e10\u003c/sup\u003e. However, the long-term phase of the 10-year plan to eliminate cholera has been launched in 2019 with an emphasis on access to clean water and sanitation. This study aimed to describe the evolution of cholera and assess the relationship between the implementation of the \u0026lsquo;coup de poing\u0026rsquo; strategy during the patron saint festivities and the incidence of cholera in the three communes of Cabaret, Carrefour, and Croix-des-Bouquets in 2017.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eData source. \u003c/strong\u003eA cholera case was defined as any patient presenting to a health facility after developing acute diarrhoeal disease with or without vomiting \u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e. Cases of cholera during the period\u003cbr /\u003e from January 1\u003csup\u003est\u003c/sup\u003e, 2017, to December 31\u003csup\u003est\u003c/sup\u003e, 2017, were obtained from the electronic databases maintained by the Ouest departmental health direction, which is updated weekly from the paper registry used by the clinical staff of the Cholera Treatment Centers. The number and date of occurrence of patron saint holidays per communal section over the period were collected from an online registry of the Ministry of Agriculture, Natural Resources and Rural Development (MANRRD) (Table 1), and the Catholic Church calendar \u003cstrong\u003e\u003csup\u003e11\u003c/sup\u003e\u003c/strong\u003e. We collected population counts and density data from the Haitian Informatics and Statistics Institute (HISI) and daily precipitation data from the National Aeronautics and Space Administration (NASA) Giovanni data analysis system \u003cstrong\u003e\u003csup\u003e12, 13\u003c/sup\u003e\u003c/strong\u003e. The components and activities of the \u0026ldquo;coup de poing\u0026rdquo; strategy were retrieved from an unpublished report of DINEPA of the \u0026lsquo;coup de poing\u0026rsquo; operation (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis. \u003c/strong\u003eFor spatial analysis, we examined the number of patronal festivities, annual case\u003cbr /\u003e count, population count, population density and annual precipitation rates per communal section.\u003cbr /\u003e Incidences per 100 inhabitants were calculated by dividing the case counts by population size. The data were imported in R\u0026reg; software (version 3.6.0. The R Foundation for Statistical Computing. April 26, 2019). Using a generalized linear model (glm) and assuming a Poisson distribution, we weighted the annual cholera incidence against the number of festivities per communal section, annual precipitation rate and population density. Since the \u0026lsquo;coup de poing\u0026rsquo; data were collected at the communal level, while our analysis was conducted at a finer scale, we used the patronal festivities as a proxy to assess the relationship between the implementation of the strategy and cholera incidence.\u003c/p\u003e\n\u003cp\u003eThe following formula was used:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eglm (formula = Incidence ~ Festivity + Density + Rain + (1|section) + (1|commune),\u003cbr /\u003e family = Poisson, data = data)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cbr /\u003e For temporal analysis, we distributed the number of patronal festivities, weekly precipitation rate\u003cbr /\u003e and case count per epidemiological week (W0). Case counts in communal sections were also\u003cbr /\u003e distributed for the 2 subsequent weeks (W1 and W2, respectively). A glm was used to assess the\u003cbr /\u003e weight of case count at W0, W1 and W2 against number of patronal festivities and weekly precipitation rates. The following formulas were used:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eglm (formula = Case.W0 ~ Festivity + Rain + (1|section) + (1|commune), family =\u003cbr /\u003e Poisson, data = data1)\u003c/li\u003e\n\u003cli\u003eglm (formula = Case.W1 ~ Festivity + Rain + (1|section) + (1|commune), family =\u003cbr /\u003e Poisson, data = data1)\u003c/li\u003e\n\u003cli\u003eglm (formula = Case.W2 ~ Festivity + Rain + (1|section) + (1|commune), family =\u003cbr /\u003e Poisson, data = data1)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor the final analysis, we combined the data of the three communes on the basis that they have similar characteristics in terms of type of land, presence of rivers and main roads and having been identified by the DELR as cholera-persistent communes (Figure 1).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn 2017, Haiti reported a total of 13 681 cases of cholera to the World Health Organization among which 3 633 suspected cholera cases were recorded in Cabaret, Carrefour and Croix-des-Bouquets \u003cstrong\u003e\u003csup\u003e14\u003c/sup\u003e\u003c/strong\u003e. The attack rates were 211.44, 17.31 and 52.28 per 10 000 inhabitants respectively. The epidemiological curve shows a persistence of cholera throughout the year, with all three communes having reported cases during all 52 epidemiological weeks of 2017, and noteworthy peaks at the 8\u003csup\u003eth\u003c/sup\u003e, 18\u003csup\u003eth\u003c/sup\u003e and 19\u003csup\u003eth\u003c/sup\u003e epidemiological weeks (Figure 2). After controlling for rainfall and population density, the implementation of the \u0026lsquo;coup de poing\u0026rsquo; strategy during the patron saint festivities was associated with a significant reduction in annual cholera incidence of 57.23% [PR=0.4277 (97.5% CI: 0.2798-0.6193), p=0.0000244] in communal sections of the three communes combined.\u003c/p\u003e\n\u003cp\u003e\u003cbr /\u003e At W0, precipitation rate [PR= 1.0000 (97.5% CI: 0.9994- 1.0007), p= 0.828] and the implementation of the \u0026lsquo;coup de poing strategy\u0026rsquo; during patronal\u003cbr /\u003e festivities [PR= 0.9638 (97.5% CI: 0.7903- 1.1617), p= 0.707] were not associated with cholera incidence.\u003c/p\u003e\n\u003cp\u003e\u003cbr /\u003e At W1, the implementation of the \u0026lsquo;coup de poing\u0026rsquo; strategy during patronal festivities [PR= 0.7458 (97.5% CI: 0.5943-0.9217), p= 0.0087] was significantly\u003cbr /\u003e associated with a reduction in cholera incidence of 25.41% in communal sections of the three communes combined, after controlling for rainfall [PR= 1.0022 (97.5% CI: 1.0016-1.0028), p= 0.00000000000127].\u003c/p\u003e\n\u003cp\u003e\u003cbr /\u003e At W2, precipitation rate [PR= 1.0030 (97.5% CI: 0.8589- 1.2504), p= 0.002*10\u003csup\u003e-13\u003c/sup\u003e] and the implementation of the \u0026lsquo;coup de poing\u0026rsquo; strategy during patronal\u003cbr /\u003e festivities [PR= 1.0420 (97.5% CI: 1.0024- 1.0036), p= 0.667] were not associated with cholera incidence (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eStudies and reports have pointed out the relationship between religious pilgrimages and cholera\u003cbr /\u003e outbreaks, such as the outbreak in Senegal between 2004 and 2006 \u003csup\u003e15, 16\u003c/sup\u003e\u003csup\u003e.\u003c/sup\u003e In a previous study in\u003cbr /\u003e 2014, Gazin observed a sudden increase in the number of cholera cases in Saint-Michel de\u003cbr /\u003e l'Attalaye, in Haiti\u0026rsquo;s Artibonite department, at approximately the same time as the local patron\u003cbr /\u003e saint festival in a nearby locality, one year after the launch of the National Plan for the\u003cbr /\u003e Elimination of Cholera in Haiti \u003csup\u003e3\u003c/sup\u003e. Cholera travels with humans. On the other hand,\u003cbr /\u003e environmental factors such as high population density and rainy seasons are known risk factors\u003cbr /\u003e for increased cholera incidence in the Democratic Republic of Congo and other African countries\u003csup\u003e17, 18\u003c/sup\u003e.\u003cbr /\u003e However, our study showed that the incidence of cholera decreases significantly a week after patronal festivities in communes of Cabaret, Carrefour and Croix-des-bouquets.\u003cbr /\u003e This finding suggests that the \u0026ldquo;coup de poing\u0026rdquo; strategy, which was deployed upstream of mass gatherings, may have contributed in mitigating the risk of cholera outbreaks in 2017.\u003c/p\u003e\n\u003cp\u003eLorraine Williams et al. studied the role of perceived risk in reducing cholera vulnerability in\u003cbr /\u003e Mozambique, depicting it as a motivator in risk management approaches \u003csup\u003e19\u003c/sup\u003e. As they emphasized,\u003cbr /\u003e periods perceived to be of greater risk for cholera transmission were associated with increased\u003cbr /\u003e vigilance and risk reduction measures. Based on the experience from the outbreak described by\u003cbr /\u003e Gazin, the concept of perceived risk might play a role in our observations, amplified by the important number of awareness initiatives conducted and individuals reached during the \u0026ldquo;coup de poing\u0026rdquo; strategy; however, more research is needed to assess the perception of risk towards infectious diseases among rural populations in Haiti during periods of patronal festivities. Furthermore, we also assessed the prevention and response strategy in relation to cholera outbreaks in Haiti.\u003c/p\u003e\n\u003cp\u003eIn the context of the elimination plan, a case-area targeted rapid response strategy, that was first implemented in 2013, involves the Haitian Ministry of Health, DINEPA and international partners such as Pan-American Health Organization and United Nations Children\u0026rsquo;s Fund. \u003csup\u003e20\u003c/sup\u003e. Various preventive and alert-response measures were thoroughly deployed from the launch in 2017 to respond to cholera alerts in a timely fashion. Patronal festivities in communal sections are occasions for which the alert-response system should be intensified in order to treat cases and prevent outbreaks. Community outreach and educational activities in areas near cases were used to reinforce the management of cases. An estimation of the effectiveness of such case-area targeted interventions in the Center department between 2015 and 2017 has shown positive outcomes in order to mitigate and shorten cholera outbreaks \u003cstrong\u003e\u003csup\u003e21\u003c/sup\u003e\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding rainfall and population density, in our study they did not influence the annual incidence of cholera or the incidence one week following patronal festivities. However, studies have previously shown a significant association between seasonal rainfall and cholera \u003csup\u003e22\u003c/sup\u003e. Hurricane Matthew, which landed in Haiti in October 2016, was followed by increased number of reported cholera cases \u003csup\u003e23\u003c/sup\u003e. Marisa et al. also showed that increased cholera incidence was associated with cumulative precipitation greater than 30 mm 4-7 days before infections were reported \u003csup\u003e24\u003c/sup\u003e. However, in the context of patronal festivities, not all communal sections experienced high rates of precipitation in the week preceding the gathering events, as the events were not all held in rainy seasons, the mean rate of precipitation being 38.78 mm. A study has identified a link between cholera and social factors such as population density in vulnerable areas \u003cstrong\u003e\u003csup\u003e25\u003c/sup\u003e\u003c/strong\u003e. Nonetheless, communal sections in Haiti are largely unurbanized, therefore the incidence of cholera might be associated with different factors such as the practice of latrine sharing \u003cstrong\u003e\u003csup\u003e26\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and perspectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLimitations of this study are attributable to the quality of the data recorded in the source\u003cbr /\u003e databases and then entered into our database, specifically with regard to the origin of the\u003cbr /\u003e patients. The origin of the patients was not recorded in all cases. In addition, the population densities of the communal sections used in this analysis are dated to 2015, based on the latest HISI estimates. These data may not reflect the current situation in the communal sections. Furthermore, as there is no national registry of interventions, data regarding cholera interventions prior to the \u0026lsquo;coup de poing\u0026rsquo; strategy could not be integrated in the model. Based on our findings, further investigations should emphasize the impact of interventions following patronal festivities on cholera incidence.\u003c/p\u003e\n\u003cp\u003eWe attempted to control for failure of the surveillance system during the study period using the surveillance completion data. However, this data is only collected at the departmental level (first administrative level) and could not be integrated in our model. It is likely that our observations might be due to decreased cholera case reporting from the cholera treatment centers and decreased health care attendance as health care workers and patients focus on the festivities.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We also were not able to assess the relationship with particular interventions of the \u0026lsquo;coup de poing\u0026rsquo; strategy since data were collected at the communal level. However, the patronal festivities are the best proxy to the extent of our knowledge. This emphasizes the need to collect intervention data systematically at all administrative levels. Our study being inaugural, it opens doors to further investigations of spatial and temporal dynamics of cholera in regards to preventive interventions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSociocultural factors contribute to the human-to-human transmission of cholera. In 2017, the\u003cbr /\u003e cholera epidemic showed a persistent pattern in three communes in the Ouest department in\u003cbr /\u003e Haiti. In this study, our model revealed a statistically significant association between the implementation of the \u0026lsquo;coup de poing\u0026rsquo; strategy during patronal festivities and a reduction in cholera incidence. The findings in this study suggest that that the multi-partner \u0026lsquo;coup de poing\u0026rsquo; strategy may have contributed to the reduced cholera incidence during patron saint festivities and in Ouest department in Haiti 2017.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDELR: Department of Epidemiology, Laboratories and Research; DINEPA: Direction National d\u0026rsquo;Eau Potable et d\u0026rsquo;Assainissement; GLM: Generalized Linear Model; HISI: Haitian Informatics and Statistics Institute; MANRRD: Ministry of Agriculture, Natural Resources and Rural Development; NASA: National Aeronautics and Space Administration.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Ethical Review Committee of Haiti\u0026rsquo;s Ministry of Health.\u003cbr /\u003e Databases were anonymized to ensure confidentiality.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eThe authors consent to Editorial Board of the journal BMC to publish the paper. The author\u003cbr /\u003e accepts responsibility for publishing this material in his own name, as well as on behalf of all co-\u003cbr /\u003e authors.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding\u003cbr /\u003e author on reasonable request. The Ouest departmental health direction database is close to public access. We obtained administrative permission to access and use it for this study. The MANRRD (\u003ca href=\"http://agriculture.gouv.ht/statistiques_agricoles/EnqueteCommunautaire/documents/DEP05.html\"\u003ehttp://agriculture.gouv.ht/statistiques_agricoles/EnqueteCommunautaire/documents/DEP05.html\u003c/a\u003e.), HISI (\u003ca href=\"https://web.archive.org/web/20151106110552/http:/www.ihsi.ht/pdf/projection/Estimat_PopTotal_18ans_Menag2015.pdf\"\u003ehttps://web.archive.org/web/20151106110552/http://www.ihsi.ht/pdf/projection/Estimat_PopTotal_18ans_Menag2015.pdf\u003c/a\u003e) and NASA (\u003ca href=\"https://giovanni.gsfc.nasa.gov/giovanni/\"\u003ehttps://giovanni.gsfc.nasa.gov/giovanni/\u003c/a\u003e) data are available online and public access is open.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eAuthors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003cstrong\u003e\u003cbr /\u003e \u003c/strong\u003eThe authors did not receive funding for this study.\u003c/p\u003e\n\u003cp\u003eAuthor\u0026rsquo;s contributions\u003c/p\u003e\n\u003cp\u003eKM and AMA conceived the idea. KM and BB collected data. KM, AMA and DB did the\u003cbr /\u003e analysis and interpretation of data. KM wrote the manuscript. AMA, DB, BB, SR, GL, JHH and\u003cbr /\u003e CR reviewed the manuscript and made intellectual input. All authors read and approved the final\u003cbr /\u003e manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003cstrong\u003e\u003cbr /\u003e \u003c/strong\u003eMany thanks to the staff of DELR for their support during data collection.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e1- Morris JG Jr., 2011. Cholera--modern pandemic disease of ancient lineage.\u0026nbsp;Emerg Infect Dis.; 17(11):2099-2104. doi:10.3201/eid1711.111109\u003c/p\u003e\n\u003cp\u003e2- Rebaudet S, Sudre B, Faucher B, Piarroux R., 2013. Environmental determinants of cholera outbreaks in inland Africa: a systematic review of main transmission foci and propagation routes. J infect Dis. 208(supplement 1):S46-S54\u003c/p\u003e\n\u003cp\u003e3-Gazin P, Barrais R, Uwineza F., 2017. Risk factors of cholera transmission in rural areas in Haiti. Med Sante Trop. 27(1):11-15\u003c/p\u003e\n\u003cp\u003e4- Direction d'Epid\u0026eacute;miologie, des Laboratoires et de la Recherche, 2016. Plan National d'Elimination du Chol\u0026eacute;ra. Minist\u0026egrave;re de la Sant\u0026eacute; Publique et de la Population\u003c/p\u003e\n\u003cp\u003e5- UNICEF Haiti: Launch of 2018 Operation \u0026ldquo;Coup de Poing\u0026rdquo; against cholera. \u003ca href=\"https://medium.com/@haitiunicef/launch-of-2018-operation-coup-de-poing-against-cholera-fb379eceb03b\"\u003ehttps://medium.com/@haitiunicef/launch-of-2018-operation-coup-de-poing-against-cholera-fb379eceb03b\u003c/a\u003e. Accessed March 23, 2020.\u003c/p\u003e\n\u003cp\u003e6- Burnett EM,\u0026nbsp;Francois J,\u0026nbsp;Sreenivasan N,\u0026nbsp;Wannemuehler K,\u0026nbsp;Faye PC,\u0026nbsp;Tohme RA,\u0026nbsp;et al. 2019.\u0026nbsp;Oral cholera vaccination coverage after the first global stockpile deployment in Haiti, 2014.\u0026nbsp;Vaccine\u0026nbsp;37:\u0026nbsp;6348\u0026ndash;6355.\u003c/p\u003e\n\u003cp\u003e7- Guillaume Y, Ternier R, Vissieres K, Casseus A, Chery MJ, Ivers LC., 2018. Responding to cholera in Haiti\u0026nbsp;: Implications for the national plan to eliminate cholera by 2022. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188568/\"\u003eJ Infect Dis\u003c/a\u003e. 2018 Nov 15; 218(Suppl 3): S167\u0026ndash;S170.\u003c/p\u003e\n\u003cp\u003e8- Tohme RA, Fran\u0026ccedil;ois J, Wannemuehler K, et al., 2013. Oral Cholera Vaccine Coverage, Barriers to Vaccination, and Adverse Events following Vaccination, Haiti.\u0026nbsp;Emerg Infect Dis. 2015;21(6):984-991. doi:10.3201/eid2106.141797\u003c/p\u003e\n\u003cp\u003e9- Ivers LC, Teng JE, Lascher J, et al., 2013. Use of oral cholera vaccine in Haiti: a rural demonstration project.\u0026nbsp;Am J Trop Med Hyg.; 89(4):617-624. doi:10.4269/ajtmh.13-0183\u003c/p\u003e\n\u003cp\u003e10- Minist\u0026egrave;re de la Sant\u0026eacute; Publique et de la Population, 2020. Profil statistique du chol\u0026eacute;ra. \u003ca href=\"https://www.mspp.gouv.ht/documentation.php\"\u003ehttps://www.mspp.gouv.ht/documentation.php\u003c/a\u003e [Accessed August 23, 2020]\u003c/p\u003e\n\u003cp\u003e11- Minist\u0026egrave;re de l'Agriculture, des Ressources Naturelles et du D\u0026eacute;veloppement Rural, 2008. Enqu\u0026ecirc;te Communautaire. 2008. http://agriculture.gouv.ht/statistiques_agricoles/EnqueteCommunautaire/documents/DEP05.html. [Accessed on January 24, 2019]\u003c/p\u003e\n\u003cp\u003e12- Institut Haitien de Statistique et d'Informatique, 2015. Population totale, de 18 ans et plus, m\u0026eacute;nages et densit\u0026eacute;s estim\u0026eacute;s en 2015. Minist\u0026egrave;re de l'Economie et des Finances\u003c/p\u003e\n\u003cp\u003e13- Acker JG, Leptoukh G., 2007. Online Analysis Enhances Use of NASA Earth Science Data. Eos, Trans. AGU. 88(2):14-17\u003c/p\u003e\n\u003cp\u003e14- World Health Organization. 2017. Cholera, 2017. \u003ca href=\"https://apps.who.int/iris/bitstream/handle/10665/274655/WER9338-489-497.pdf?sequence=1\u0026amp;isAllowed=y\"\u003ehttps://apps.who.int/iris/bitstream/handle/10665/274655/WER9338-489-497.pdf?sequence=1\u0026amp;isAllowed=y\u003c/a\u003e [Accessed online on August 7, 2020]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e15- Thompson F., 2010. Water woes in Senegal's holy city. Bull World Health Organ. 88(1):7\u0026ndash;8. doi:10.2471/BLT.10.020110\u003c/p\u003e\n\u003cp\u003e16- Manga NM,\u0026nbsp;Ndour CT,\u0026nbsp;Diop SA\u0026nbsp;et al., 2008. Cholera in Senegal from 2004 to 2006: lessons learned from successive outbreaks. Medecine Tropicale: revue du Corps de sante colonial,\u0026nbsp;68\u0026nbsp;(6)\u0026nbsp;(2008), pp.\u0026nbsp;589-592\u003c/p\u003e\n\u003cp\u003e17- Rebaudet S, Sudre B, Faucher B, Piarroux R., 2013. Environmental determinants of cholera outbreaks in inland Africa: a systematic review of main transmission foci and propagation routes. J infect Dis. 208(supplement 1):S46-S54\u003c/p\u003e\n\u003cp\u003e18- Deen J, Mengel MA, Clemens JD. 2020. Epidemiology of cholera.\u0026nbsp;Vaccine. 38 Suppl 1:A31-A40. doi:10.1016/j.vaccine.2019.07.078\u003c/p\u003e\n\u003cp\u003e19- Lorraine W et al., 2020. The Role of Risk Perception in Reducing Cholera Vulnerability. Risk Management, vol. 12, no. 3, 2010, pp. 163\u0026ndash;184. JSTOR, www.jstor.org/stable/40660681. Accessed 18 Mar. 2020.\u003c/p\u003e\n\u003cp\u003e20- Rebaudet S, Bulit G, Gaudart J, et al., 2019. The case-area targeted rapid response strategy to control cholera in Haiti: a four-year implementation study. PLoS Negl Trop Dis.;13(4):e0007263\u003c/p\u003e\n\u003cp\u003e21- Michel E, Gaudart J, Beaulieu S, Bulit G, Piarroux M, Boncy J, Dely P, Piarroux R, Rebaudet S., 2019. Estimating effectiveness of case-area targeted response interventions against cholera in Haiti.\u0026nbsp;Elife. 8:e50243. doi:10.7554/eLife.50243\u003c/p\u003e\n\u003cp\u003e22- Lemaitre J, Pasetto D, Perez-Saez J, Sciarra C, Wamala JF, Rinaldo A, 2019. Rainfall as a driver of epidemic cholera: Comparative model assessments of the effect of intra-seasonal precipitation events, Acta Tropica, Volume 190, Pages 235-243, ISSN 0001-706X, \u003ca href=\"https://doi.org/10.1016/j.actatropica.2018.11.013\"\u003ehttps://doi.org/10.1016/j.actatropica.2018.11.013\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003e23- Hulland E, Subaiya S, Pierre K, et al., 2019. Increase in Reported Cholera Cases in Haiti Following Hurricane Matthew: An Interrupted Time Series Model. Am J Trop Med Hyg.;100(2):368\u0026ndash;373. doi:10.4269/ajtmh.17-0964\u003c/p\u003e\n\u003cp\u003e24- Eisenberg MC, Kujbida G, Tuite AR, Fisman DN, Tien JH, 2013. Examining rainfall and cholera dynamics in Haiti using statistical and dynamic modeling approaches, Epidemics, Volume 5, Issue 4, Pages 197-207, ISSN 1755-4365, \u003ca href=\"https://doi.org/10.1016/j.epidem.2013.09.004\"\u003ehttps://doi.org/10.1016/j.epidem.2013.09.004\u003c/a\u003e.\u003c/p\u003e\n\u003cp\u003e25- Saha A, Hayen A, Ali M, Rosewell A, Clemens JD, MacIntyre CR, Qadri F, 2017. Socioeconomic risk factors for cholera in different transmission settings: An analysis of the data of a cluster randomized trial in Bangladesh, Vaccine, Volume 35, Issue 37, Pages 5043-5049, ISSN 0264-410X, https://doi.org/10.1016/j.vaccine.2017.07.021.\u003c/p\u003e\n\u003cp\u003e26- Matias WR, Teng JE, Hilaire IJ, Harris JB, Franke MF, Ivers LC., 2017. Household and Individual Risk Factors for Cholera among Cholera Vaccine Recipients in Rural Haiti.\u0026nbsp;Am J Trop Med Hyg., 97(2):436\u0026ndash;442. doi:10.4269/ajtmh.16-0407\u003c/p\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" width=\"623\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"623\"\u003e\n\u003cp\u003eTable 1. Patron Saint Festivities at communal sections level in 3 communes in Haiti\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCommunes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003eCommunal sections\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003ePatron saints\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eDate of occurrence\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCabaret\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e1\u003csup\u003e\u0026egrave;re\u003c/sup\u003e section Boucassin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSaint Agn\u0026egrave;s\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJuly 16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCabaret\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e2\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Boucassin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eMont Carmel\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJuly 16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCabaret\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e2\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Boucassin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSaint Joseph\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eMarch 19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCabaret\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e3\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Source Matelas\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSaint G\u0026eacute;rard\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eOctober 6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCabaret\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e4\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Fonds des Blancs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSaint Michel\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eSeptember 29\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e1\u003csup\u003e\u0026egrave;re\u003c/sup\u003e section Varreux\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSainte Th\u0026eacute;r\u0026egrave;se\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eOctober 1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e2\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Varreux\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eMarie Madeleine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJuly 22\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e2\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Varreux\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eMichel-Ange\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eSeptember 30\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e3\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Petit Bois\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSaint Antoine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJune 3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e4\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Petit Bois\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eNotre Dame du Rosaire\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJune 24\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e4\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Petit Bois\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eNotre-Dame du Perp\u0026eacute;tuel Secours\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eOctober 7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e5\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Petit Bois\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eNotre Dame de Lamercie\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eSeptember 24\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e6\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Belle Fontaine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eNotre Dame Deslourdes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eFebruary 11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e9\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Crochus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSainte Marie joseph\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eFebruary 4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e10\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section des Orangers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSainte Genevi\u0026egrave;ve\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJanuary 3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCroix-des-Bouquets\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e10\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section des Orangers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSainte Th\u0026eacute;r\u0026egrave;se de l\u0026rsquo;Enfant J\u0026eacute;sus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eOctober 3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCarrefour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e3\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Ta\u0026iuml;fer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSainte Croix\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eSeptember 14\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCarrefour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e7\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Lavalle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSaint Joseph\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eMarch 19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCarrefour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e7\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Lavalle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSainte Th\u0026eacute;r\u0026egrave;se de l\u0026rsquo;Enfant J\u0026eacute;sus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eOctober 1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCarrefour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e9\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Bizoton\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eMont Carmel\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJuly 16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCarrefour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e10\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Thor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSaint Charles\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eNovember 4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCarrefour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e10\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Thor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eNotre-Dame du Perp\u0026eacute;tuel Secours\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eJune 27\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"101\"\u003e\n\u003cp\u003eCarrefour\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"184\"\u003e\n\u003cp\u003e11\u003csup\u003e\u0026egrave;me\u003c/sup\u003e section Rivi\u0026egrave;re Froide\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eSainte-Th\u0026eacute;r\u0026egrave;se de l'Enfant J\u0026eacute;sus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"150\"\u003e\n\u003cp\u003eOctober 1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"623\"\u003e\n\u003cp\u003eSource: Ministry of Agriculture, Natural Resources and Rural Development, 2008. Community survey, Definitive results. http://agriculture.gouv.ht/statistiques_agricoles/EnqueteCommunautaire/documents/DEP05.html. Published online in 2008. Accessed on January 24, 2019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"623\"\u003e\n\u003cp\u003eTable 2. Components and activities of the \u0026lsquo;coup de poing\u0026rsquo; strategy deployed in the Ouest department in Haiti, 2017\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eComponents\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eActivities\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eCoordination\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; 55 situation room meetings\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eEpidemiologic surveillance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Daily action-oriented epidemiologic analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eInvestigation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; More than 7 multisectoral and multi-partnered investigations\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eCare delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; 30 supervision visits of Diarrheal Treatment Centers\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; 10 follow-up visits\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Training of 20 nurses, 7 nursing assistants and 10 hygienists\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Installation and rehabilitation of equipment on 3 outbreak sites by partner NGOs\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Supply of treatment centers with materials and establishment of a contingency stock\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Transport of specimen to the National public health laboratory by partner NGOs\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eCommunity response and water, sanitation and hygiene\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Deployment of 26 mobile teams\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Distribution of 8 929 sanitary kits\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Distribution of 644 123 oral rehydration solutions\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Operation of 14 058 water point decontaminations\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Installation of 69 chlorination points\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Installation of 17 hand washing points\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Organization of 78 mass awareness sessions in marketplaces, churches and schools\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Distribution of 10 744 flyers containing awareness messages\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003eCommunication\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"312\"\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Training of 401 focal points in local town halls\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Training of 108 marketplace directors, 155 grassroot organizations directors and 136 funeral directors\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; 43 street theater performances reaching 4 200 individuals\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; 30 public transportation debates reaching 7 350 individuals\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Distribution of T-shirts and USB with awareness messages reaching 9 600 individuals\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; 6 workshops targeting 210 religious leaders\u003c/p\u003e\n\u003cp\u003e\u0026sect;\u0026nbsp; Involvement of 85 churches reaching 17 000 individuals\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"623\"\u003e\n\u003cp\u003eSource: DINEPA, 2017. [Report] Results of the \u0026lsquo;coup de poing\u0026rsquo; strategy against cholera, Ouest department, Haiti.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003e\n\u003cp\u003eTable 3. Model parameters and Prevalence Ratios of the Generalized Linear Model selected for cholera cases following patronal festivities at W0, W1 and W2 in communal sections, Haiti, 2017*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003eCharacteristic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eCoefficient estimate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eStandard error\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eZ value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003ePr(\u0026gt;|t|)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003ePrevalence Ratio\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eCI (2.5-97.5) %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003eIntercept 2017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-55.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e30.60\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-1.83\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.07\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e5.11*10\u003csup\u003e-25\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e2.40*10\u003csup\u003e-52\u003c/sup\u003e - 3.86\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePatronal festivities in 2017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-8.49*10\u003csup\u003e-1\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e2.01*10\u003csup\u003e-1\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-4.22\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003e2.44*10\u003csup\u003e-5\u003c/sup\u003e ***\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.43\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e2.80*10\u003csup\u003e-1\u003c/sup\u003e - 0.62\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003eDensity in 2017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-2.09*10\u003csup\u003e-4\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.37*10\u003csup\u003e-5\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-6.20\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003e5.83*10\u003csup\u003e-10\u003c/sup\u003e ***\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e10.00*10\u003csup\u003e-1\u003c/sup\u003e - 1. 00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePrecipitations in 2017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e2.97*10\u003csup\u003e-2\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.52*10\u003csup\u003e-2\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.95\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003e0.05\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00 - 1.06\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003eIntercept W0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e64.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u0026lt;2*10\u003csup\u003e-16\u003c/sup\u003e ***\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e4.10\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.93 \u0026ndash; 4.28\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePatronal festivities at W0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-0.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-0.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.96\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.79 - 1.16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePrecipitations at W0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.78*10\u003csup\u003e-5\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.60*10\u003csup\u003e-4\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u0026nbsp;0.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00 - 1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003eIntercept W1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.02\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e60.19\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u0026lt;2*10\u003csup\u003e-16\u003c/sup\u003e ***\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.79\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.63 - 3.96\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePatronal festivities at W1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-0.29\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.11\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e-2.62\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003e1.871*10\u003csup\u003e-2\u003c/sup\u003e **\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.75\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.59 - 0.92\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePrecipitations at W1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.02*10\u003csup\u003e-1\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.03*10\u003csup\u003e-2\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e7.10\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003e1.27e-12 ***\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00 - 1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003eIntercept W2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.30\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.02\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e57.46\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u0026lt;2*10\u003csup\u003e-16\u003c/sup\u003e ***\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.65\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e3.50 - 3.82\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePatronal festivities at W2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.04\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.10\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.43\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.67\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.04\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.86 - 1.25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003ePrecipitationss at W2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.03*10\u003csup\u003e-1\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e0.31*10\u003csup\u003e-3\u003c/sup\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e9.74\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;2*10\u003csup\u003e-16\u003c/sup\u003e ***\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e1.00 - 1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003e\n\u003cp\u003e*Coefficient estimate, regression coefficients (for discrete variables, their exponential gives the Odds ratio) ; z value, value of the t distribution; Pr(\u0026gt;|t|), probability of the null hypothesis of a coefficient estimate not statistically different from zero ; CI, confidence interval; intercept, average number of cases.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cholera, Patronal festivities, Mass gatherings, Haiti","lastPublishedDoi":"10.21203/rs.3.rs-28562/v4","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-28562/v4","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Introduction: Religious pilgrimages are among the anthropogenic factors known to be associated with the\ntransmission of diarrheal diseases, such as cholera. This ecological study aimed to describe the evolution of cholera and assess the relationship between the implementation of the ‘coup de poing’ strategy during the patron saint festivities and the incidence of cholera in the three communes of Cabaret, Carrefour, and Croix-des-Bouquets in Haiti in 2017.\n \nMaterials/Methods: An epidemiological curve was produced to illustrate the evolution of cholera at the communal level. Generalized linear models assuming a Poisson distribution were used to weight the annual\ncholera incidence of communal sections against variables such as the number of patronal\nfestivities, population density and annual precipitation rates. The number of cases in the week of\nthe festivity as well as one and two weeks later was weighted against patronal festivities and\nweekly precipitation rates.\n \nResults: In total, 3 633 suspected cholera cases were continuously reported in three communes in Haiti\n(Cabaret, Carrefour, Croix-des-bouquets) during the 52-epidemiological week period in 2017.\nAfter controlling for rainfall and population density, the implementation of the ‘coup de poing’ strategy during the patron saint festivities was associated with a significant reduction in cholera incidence of 57.23% [PR=0.4277 (97.5% CI: 0.2798-0.6193), p=0.0000244]. The implementation of the strategy was associated with a reduction in cholera incidence of 25.41% one week following patronal festivities.\n \nConclusion: This study showed a continuous presence of cholera in three communes in Haiti in 2017 and an\nassociation between the implementation of the ‘coup de poing’ strategy during patronal festivities and a reduction in cholera incidence. The findings imply that the multi-partner ‘coup de poing’ strategy may have contributed to the reduced cholera incidence following patron saint festivities and in Ouest department in Haiti in 2017.","manuscriptTitle":"Impact of Patron Saint Festivities on Cholera in Three Communes in Haiti","msid":"","msnumber":"","nonDraftVersions":[{"code":4,"date":"2020-09-24 01:14:05","doi":"10.21203/rs.3.rs-28562/v4","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2020-09-23T12:00:00+00:00","index":"","fulltext":""},{"type":"decision","content":"Accept","date":"2020-09-23T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":3,"date":"2020-09-18 15:31:14","doi":"10.21203/rs.3.rs-28562/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2020-09-16T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-15T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-08-31 03:20:24","doi":"10.21203/rs.3.rs-28562/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-09-05T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"editorInvitedReview","content":"","date":"2020-09-02T12:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-30T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-27T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-08-27T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-08-26T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-25T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-25T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-05-15 16:02:00","doi":"10.21203/rs.3.rs-28562/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-08-03T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-27T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nPEER REVIEWER ASSESSMENTS:\n\nOBJECTIVE - Full research articles: is there a clear objective that addresses a testable research question(s) (brief or other article types: is there a clear objective)?\nYes - there is a clear objective\n\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\nNo - there are minor issues\n\nEXECUTION - Are the experiments and analyses performed with technical rigor to allow confidence in the results?\nNo - there are minor issues\n\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\nNo - there are issues with the statistics in the study\n\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\nNo - there are minor issues\n\nOVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically sound? If not, can revisions be made to make the work technically sound?\nProbably - with minor revisions\n\nPEER REVIEWER COMMENTS:\n\nGENERAL COMMENTS:\nThis ecological study aimed to describe the epidemiology of cholera in three communes in Haiti (Cabaret, Carrefour and Croix-des- Bouquets) in 2017 and assess the spatiotemporal influence of patron saint festivities on cholera incidence in communal sections. The study is very interesting and provides some useful insights. However there are some important questions about the analysis that needs to be answered to validate the methodology used and the conclusions drawn.\n\nREQUESTED REVISIONS:\nThe main questions are about the study design. Line 97, What is meant here by 'festivity count?' is this the number of festivities or the number of persons attending festivities? Provide more details on what format was the festivities count in for analysis in the regression model. It is unclear from the Table and figure how this data was incorporated into the analysis.\n\nWhat about the Cholera related interventions? This analysis should indicate when and how these interventions were implemented and how they were considered as part of the analysis as this is potentially a significant confounder..\nLines 101- 104: How do we know that these events are so unique, since the rates of cholera for the week before the festivities was not examined? In addition, what does the data look like for the entire year? This is important to set the context for the significance of the results reported.\nLine 117-118: Is the significantly reduce incidence for all three communes combined? This needs to be clarified in the text.\nLine 122, Change 'cholera case' to 'cholera incidence'.\nResults, Table 2: Was there any difference in the rates for individual communes included in the analysis?\nA note on this is needed in the results section and some details on what assumptions were made to combine the data for all three communes into the final analysis.\nLines 159-163; The authors indicated that \"Various preventive and alert-response measures were thoroughly deployed from the launch in 2017 to respond to cholera alerts in a timely fashion\" yet there was no attempt to analyse how these interventions impacted on the outcomes.\nLines 180-182 - limitations indicate that 'Furthermore, as there is no national registry of interventions, data regarding cholera interventions could not be integrated in the model.' It is highly plausible that these interventions occurring around the festivities have impacted on the outcomes observed? Could there be other reasons for the outcomes observed especially in the context that the week 2 results were non-significant. Would the impact of interventions have reduced so soon afterwards?* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-15T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-04T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nReviewer Comments:\n\nGeneral comments:\n\nA well thought-out study that seeks to document the effectiveness of cholera control interventions that are being implemented as part of the 2019 national cholera plan to eliminate cholera from Haiti.\n\n\nAbstract:\n\nIntroduction:\n\nLine 32: Ecological studies only assess relationships between exposure and outcome but cannot be used to establish the influence of the exposure on the outcome. Therefore the word 'influence' (line 32) should be replaced with 'relationship'\n\nMaterials and methods:\n\nLines 35-40: The model used has far less co-variates and is therefore insufficiently powered to control for confounding from:\n1. Existing interventions in local communities as part of the national cholera outbreak control\n2. Cholera vaccination coverage (both preventive and reactive) as part of the outbreak response and control\n3. Interventions to improve access to safe water; sanitation facilities; and personal hygiene as part of outbreak response.\n4. There could also be confounding from low reporting during the festivities as some of the health workers will be involved in the festivities and the healthcare seeking behaviors during these periods are low.\n\nThese should be added as covariates to the model otherwise; this current model is confounded to a great extent by these variables.\n\nThe authors should also state if in 2017; there was mass gathering planning ahead of the festivities and such planning may entail hygiene promotion by availing hand washing facilities with chlorinated water or soap and water; improved access to sanitation facilities for the pilgrims; promotion of safe food hygiene practices; and pretravel cholera vaccination for the pilgrims\n\nResults:\n\nLines 44-45: Since this is an ecological study (that assesses relationships but cannot be used to assess temporal association between exposure and outcome) it is not correct to state that 'Patronal festivities significantly reduced the annual incidence of cholera by 57.23%'. Ecological studies are not powered to make such a conclusion due to many confounders that are not controlled for and due to the fact that the assessment for most variables is done at population level.\n\n\n\nConclusion\n\nLines 48-51: this observation could be coincidental and may be attributed to failure to control for other confounders as highlighted from the comments to materials and methods section.\n\nMain article\n\nIntroduction\nLines 68-72: In relation to the multi partner 'coup de poing' strategy:\n1. Did it include a component of improving access to safe drinking water and improved sanitation facilities?\n2. What did community response entail?\n3. Was oral cholera vaccination included in the intervention package?\n4. This strategy needs to be well described.\n\nLines 75-77: The multi-partner 'coup de poing' strategy entailed outbreak response activities in affected communes, and these were reinforced during the festivities.\n\nTherefore the study aim needs to be restated to indicate that it is the relationship between implementation of the 'coup de poing' strategy during the patron saint festivities and the incidence of cholera in the three selected communes that needs to be established.\n\nFor example; the revised study intent may read as;\n'The study aimed to describe the evolution of cholera and assess the relationship between the implementation of the 'coup de poing' strategy during the patron saint festivities and the incidence of cholera in the three communes of Cabaret, Carrefour, and Croix-des-Bouquets in 2017'.\n\nMaterials and methods\n\nLines 80-81: The cholera case definition should be rewritten to read as: 'A cholera case was defined as any patient presenting to a health facility after developing acute diarrhoeal disease with or without vomiting'.\n\nAlso, the components of the multi-partner 'coup de poing' intervention should be described in detail under the well described.\n\nResults\n\nLines 116-118: The sentence should be revised to read as: 'After controlling for rainfall and population density, the implementation of the 'coup de poing' strategy during the patron saint festivities was associated with a significant reduction in cholera incidence of 57.23% [PR=0.4277 (97.5% CI: 0.2798-0.6193), p=0.0000244].'\n\n\n\nDiscussion\n\nLines 145-147: These two sentences are misplaced in the discussion and show that the authors failed to link the literature that showed cholera case escalation during patron saint festivities in the past and the eventual launching of the multi-partner 'coup de poing' strategy to mitigate the risk of cholera. The intent of the study was therefore to assess the association between this strategy and the incidence of cholera. This logic should therefore be used to interpret the results as part of the discussion.\n\nHowever, reading lines 145-147; shows that the authors have not able tie all these pieces together to make sense of the study findings. These lines (145-147) should be rewritten and aligned to the literature; the main intervention being assessed in relation to the festivities; and the study results.\n\nLines 148-155: The authors postulate that perceived risk could have contributed to the reduction of cholera incidence in relation to the interventions around the festivities. The authors need to dig into the intervention components of the multi-partner 'coup de poing' strategy to determine which intervention could have influenced and enhanced the perceived risk among the pilgrims during the 2017 festivities.\n\nLines 156-158: You earlier on indicated that the cholera elimination plan was launched in 2019 (lines 74-75). This new plan embodies the case-area targeted rapid response strategy that was first used in 2013. If this is the case; then the sentence (line 156-158) needs to be revised to read as;\n\n'In the context of the elimination plan, a case-area targeted rapid response strategy, that was first implemented in 2013, involves the Haitian Ministry of Health, DINEPA and international partners such as Pan-American Health Organization and United Nations Children's Fund.'\n\nLines 176-183: Confounding from co-variates that were not integrated into the model should be cited as a major limitation of the study. This is a major threat to the internal validity of the study findings.\n\nThe other confounder for the reduced incidence of cholera is the likelihood of reduced cholera case reporting rates from the cholera treatment centers and the reduced health care attendance as everyone including the healthcare workers and patient co-attendants will be focused on the festivities.\n\nConclusion\n\nLines 188-190; Revise the conclusion as recommended before to highlight the significant association between the interventions implemented in association with patron saint festivities and the reduction in cholera incidence.\n\nLines 190-191: The sentence should be re-written as:\n\n'The findings in this study suggest that that the multi-partner 'coup de poing' strategy may have contributed to the reduced cholera incidence during patron saint festivities and in Ouest department in Haiti 2017.' \n\nThank you,\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n"},{"type":"reviewerAgreed","content":"","date":"2020-05-18T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-04-14T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-03-24T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-03-24T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-03-23T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-03-23T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"331c9ea4-d105-4238-83f7-5c8aec5954a5","owner":[],"postedDate":"September 24th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":552246,"name":"Health Policy"},{"id":552247,"name":"Infectious Diseases"}],"tags":[],"updatedAt":"2020-10-04T15:02:20+00:00","versionOfRecord":{"articleIdentity":"rs-28562","link":"https://doi.org/10.1186/s12889-020-09601-9","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2020-10-01 12:00:00","publishedOnDateReadable":"October 1st, 2020"},"versionCreatedAt":"2020-09-24 01:14:05","video":"","vorDoi":"10.1186/s12889-020-09601-9","vorDoiUrl":"https://doi.org/10.1186/s12889-020-09601-9","workflowStages":[]},"version":"v4","identity":"rs-28562","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-28562","identity":"rs-28562","version":["v4"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}