Abstract
BackgroundIn Bangladesh, pharmacy-purchased oral rehydration solution (ORS) is often used to treat diarrhea, including cholera. Over-the-counter sales have been used for epidemiologic surveillance in the past, but rarely, if ever, in low-income countries. With few early indicators for cholera outbreaks in endemic areas, diarrhea-related product sales may serve as a useful surveillance tool.Methodology/Principal FindingsWe tracked daily ORS sales at 50 pharmacies and drug-sellers in an urban Bangladesh community of 129,000 for 6-months while simultaneously conducting surveillance for diarrhea hospitalizations among residents. We developed a mobile phone based system to track the sales of ORS and deployed it in parallel with a paper-based system. Our objectives were to determine if the mobile phone system was practical and acceptable to pharmacists and drug sellers, whether data were reported accurately compared to a paper-based system, and whether ORS sales were associated with future incidence of cholera hospitalizations within the community. We recorded 47,215 customers purchasing ORS, and 315 hospitalized diarrhea cases, 22% of which had culture-confirmed cholera. ORS sales and diarrhea incidence were independently associated with the mean daily temperature; therefore both unadjusted and adjusted models were explored. Through unadjusted cross-correlation statistics and generalized linear models, we found increases in ORS sales were significantly associated with increases in hospitalized diarrhea cases up to 9-days later and hospitalized cholera cases up to one day later. After adjusting for mean daily temperature, ORS was significantly associated with hospitalized diarrhea two days later and hospitalized cholera one day later.Conclusions/SignificancePharmacy sales data may serve as a feasible and useful surveillance tool. Given the relatively short lagged correlation between ORS sales and diarrhea, rapid and accurate sales data are key. More work is needed in creating actionable algorithms that make use of this data and in understanding the generalizability of our findings to other settings.
Highlights
Despite well over a hundred years of research on the disease, cholera remains a threat to public health in many parts of the world, causing more than 2–3 million cases each year and over 100,000 deaths [1]
Over-the-counter sales have been used for epidemiologic surveillance in the past, but rarely, if ever, in low-income countries
Over-the-counter sales have been used for epidemiologic surveillance, but rarely in low-income countries
Summary
Despite well over a hundred years of research on the disease, cholera remains a threat to public health in many parts of the world, causing more than 2–3 million cases each year and over 100,000 deaths [1]. Most cholera surveillance systems in endemic countries are passive and clinic-based; capturing only the severe cases that are able to access healthcare services. In Bangladesh, people commonly use oral rehydration solution (ORS) purchased at pharmacies to treat diarrhea, including Vibrio cholerae, in part due to years of mass educational campaigns and social marketing [3,4,5,6]. Trends in the sales of different diarrhea-related products may serve as a useful tool for detecting increases in cholera within a community, perhaps before clinic-based surveillance systems detect the signal of an outbreak. In Bangladesh, pharmacy-purchased oral rehydration solution (ORS) is often used to treat diarrhea, including cholera. With few early indicators for cholera outbreaks in endemic areas, diarrhea-related product sales may serve as a useful surveillance tool.
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