Spatial clustering of cholera cases in the Kathmandu Valley: implications for a ring vaccination strategy

Int Health. 2021 Feb 24;13(2):170-177. doi: 10.1093/inthealth/ihaa042.


Background: In mid-2016, a cholera outbreak occurred in Kathmandu Valley, Nepal. This retrospective study aims to determine if a reactive, ring vaccination strategy would have been useful in preventing cholera transmission during that outbreak.

Methods: Data on cholera cases were collected as part of hospital-based surveillance in the Kathmandu Valley in 2016. Global Positioning System (GPS) coordinates were obtained during household visits. Geographic clusters of cases were visually determined and tested statistically for clustering. Cluster size was determined based on the distribution of cases around the index case.

Results: GPS coordinates for 69 cases were analysed. Six geographic clusters were identified, all of which showed significant clustering of cases. Approximately 85% of cases within a cluster occurred more than 7 d after the index case. The median ring size was 1 km, with a population of 14 000 people.

Conclusions: Cholera cases were clustered in space and the majority of cases occurred over 1 week after the initial cases in the cluster, allowing for an opportunity to prevent transmission through the use of the vaccine soon after the initial case was identified. A ring vaccination strategy may be especially useful for large urban areas with recurrent seasonal outbreaks but where the specific locations for such outbreaks are not predictable.

Keywords: Nepal; cholera; oral cholera vaccine; ring vaccination.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cholera Vaccines*
  • Cholera* / epidemiology
  • Cholera* / prevention & control
  • Cluster Analysis
  • Disease Outbreaks / prevention & control
  • Humans
  • Nepal / epidemiology
  • Retrospective Studies
  • Vaccination


  • Cholera Vaccines