Culture method surveillance of Vibrio cholerae in a non-sewered sanitation refugee camp setting: Dzaleka Camp, Malawi

Refugees living in camps are particularly vulnerable to infectious disease outbreaks because of overcrowding, inadequate preventative health care, and limited water, sanitation, and hygiene services. As a result of the high disease prevalence, surveillance of cholera in Malawi provides a strong rationale for site and pathogen selection for refugee camp wastewater and environmental surveillance feasibility studies. We conducted a study in Dzaleka camp, Malawi, during a nationwide cholera outbreak. Incentivized refugee volunteers took samples for 19 weeks from seven high-use public pit latrines and a vacuum pump truck used for desludging fecal sludge. The National Microbiological Reference Laboratory of the Public Health Institute of Malawi used culture methods with confirmation via VITEK ^® MS or Analytical Profile Index to detect Vibrio cholerae . Academic partners provided technical input, training, and quality assurance through the study. The results were reviewed weekly at partner-coordination meetings. No V. cholerae was detected in samples, but one quality assurance sample tested positive during the study period. Here, we discuss the unique challenges of conducting wastewater and environmental surveillance in refugee camp settings, including our operational framework. This study provides a framework for up-scaling wastewater and environmental surveillance efforts in other humanitarian contexts through robust partnerships, processes and in-country tools.