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Randomized Controlled Trial
. 2016 Sep 13;13(9):e1002120.
doi: 10.1371/journal.pmed.1002120. eCollection 2016 Sep.

Potential for Controlling Cholera Using a Ring Vaccination Strategy: Re-analysis of Data From a Cluster-Randomized Clinical Trial

Free PMC article
Randomized Controlled Trial

Potential for Controlling Cholera Using a Ring Vaccination Strategy: Re-analysis of Data From a Cluster-Randomized Clinical Trial

Mohammad Ali et al. PLoS Med. .
Free PMC article


Introduction: Vaccinating a buffer of individuals around a case (ring vaccination) has the potential to target those who are at highest risk of infection, reducing the number of doses needed to control a disease. We explored the potential vaccine effectiveness (VE) of oral cholera vaccines (OCVs) for such a strategy.

Methods and findings: This analysis uses existing data from a cluster-randomized clinical trial in which OCV or placebo was given to 71,900 participants in Kolkata, India, from 27 July to 10 September 2006. Cholera surveillance was then conducted on 144,106 individuals living in the study area, including trial participants, for 5 y following vaccination. First, we explored the risk of cholera among contacts of cholera patients, and, second, we measured VE among individuals living within 25 m of cholera cases between 8 and 28 d after onset of the index case. For the first analysis, individuals living around each index case identified during the 5-y period were assembled using a ring to define cohorts of individuals exposed to cholera index cases. An index control without cholera was randomly selected for each index case from the same population, matched by age group, and individuals living around each index control were assembled using a ring to define cohorts not exposed to cholera cases. Cholera attack rates among the exposed and non-exposed cohorts were compared using different distances from the index case/control to define the rings and different time frames to define the period at risk. For the VE analysis, the exposed cohorts were further stratified according to the level of vaccine coverage into high and low coverage strata. Overall VE was assessed by comparing the attack rates between high and low vaccine coverage strata irrespective of individuals' vaccination status, and indirect VE was assessed by comparing the attack rates among unvaccinated members between high and low vaccine coverage strata. Cholera risk among the cohort exposed to cholera cases was 5-11 times higher than that among the cohort not exposed to cholera cases. The risk gradually diminished with an increase in distance and time. The overall and indirect VE measured between 8 and 28 d after exposure to a cholera index case during the first 2 y was 91% (95% CI 62%-98%) and 93% (95% CI 44%-99%), respectively. VE persisted for 5 y after vaccination and was similar whether the index case was a young child (<5 y) or was older. Of note, this study was a reanalysis of a cholera vaccine trial that used two doses; thus, a limitation of the study relates to the assumption that a single dose, if administered quickly, will induce a similar level of total and indirect protection over the short term as did two doses.

Conclusions: These findings suggest that high-level protection can be achieved if individuals living close to cholera cases are living in a high coverage ring. Since this was an observational study including participants who had received two doses of vaccine (or placebo) in the clinical trial, further studies are needed to determine whether a ring vaccination strategy, in which vaccine is given quickly to those living close to a case, is feasible and effective.

Trial registration: NCT00289224.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: FJL received grants from the Bill and Melinda Gates Foundation. All other authors have no competing interests.


Fig 1
Fig 1. CONSORT flow chart for assembling the population.
The ring 0–10 m includes individuals living 0.00 m to 10.00 m from the index case/control, the ring 11–15 m includes individuals living 10.01 m to 15.00 m from the index case/control, and so on.
Fig 2
Fig 2. Relative risk for cholera between cohorts of cases and cohorts of controls in spatiotemporal scales.
Since there were no cholera cases among cohorts of index controls in the 16–20-m ring during the 15–21-d time frame, the relative risk could not be calculated. The 95% confidence intervals are shown by error bars. We cut off the upper 95% CI of the 0–10-m ring and 8–14-d time frame (which is 37.36) for better visualization of all bars and their 95% CIs.

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Grant support

The original trial was conducted with financial support from the Bill and Melinda Gates Foundation through the Diseases of the Most Impoverished Program and the Cholera Vaccine Initiative grants to the International Vaccine Institute. Funding support for this study was provided by the Delivering Oral Vaccine Effectively (DOVE) project. DOVE is supported by a grant from the Bill and Melinda Gates Foundation (OPP1053556) and is administered through the Johns Hopkins Bloomberg School of Public Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.