Maintaining the Momentum Against Cholera

By Anita Zaidi

SEATTLE – When Cyclone Idai ripped through Mozambique, Malawi, and Zimbabwe on the night of March 14, it wrought unimaginable devastation and claimed more than 1,000 lives. In its aftermath, and that of Cyclone Kenneth the following month, flooding and the loss of infrastructure created the conditions for an explosive outbreak of cholera, a deadly diarrheal disease that can kill a person within hours if left untreated.

But what happened next is key: after Idai struck, the authorities launched a rapid-response initiative and within 24 hours arranged for oral cholera vaccines to be delivered to Mozambique. With a large-scale vaccination effort now underway, the outbreak is under control, and thousands of lives have been saved.

In the past, developing countries that have been struck by natural disasters or afflicted by war have not been so fortunate. After a devastating earthquake in 2010, Haiti experienced a protracted cholera outbreak that claimed thousands of lives and jeopardized its recovery. And in war-torn Yemen today, an equally widespread outbreak has yet to be brought under control.

An ancient disease, cholera once killed tens of thousands of people in Europe and North America; but it was eliminated from the Global North more than 150 years ago. Now, it is found almost exclusively in the world’s poorest communities, where it is a deadly side effect of economic deprivation and inequity.

Nonetheless, in the past 18 months, the world has made significant strides in the fight against cholera. In partnership with the governments of cholera-affected countries, the Global Task Force on Cholera Control (GTFCC), a network of leading global health organizations, is working to consign cholera to history books.

In 2018, the GTFCC arranged the shipment of 17.4 million doses of the oral cholera vaccine to affected countries. As a result, more people are vaccinated for cholera today than ever before. The cholera vaccine is not just safe and inexpensive, but also highly effective, providing immediate protection that can last for up to five years. It thus serves as a necessary bridge between emergency responses and broader, longer-term efforts such as investment in water safety, sanitation, and hygiene services.

This achievement would not have been possible without Gavi, the Vaccine Alliance. A unique public-private partnership, Gavi leverages financing for vaccination, reduces the cost of vaccines, and improves their delivery by supporting countries’ health systems. Owing to its innovative twenty-first-century fundraising and delivery model, it is one of our best assets in the fight against vaccine-preventable diseases. Better still, the oral cholera vaccine is just one of 13 vaccines that Gavi supports. Since its founding in 2000, Gavi has averted an estimated 10 million deaths – a figure that will grow as cholera outbreaks recede.

In addition to setting a new record for the delivery of oral cholera vaccines, GTFCC and Gavi are also supporting a long-term strategy led by cholera-affected countries to eradicate the disease. As outlined in Ending Cholera: A Global Roadmap to 2030, the goal is to reduce cholera deaths by 90% and eliminate the disease from 20 of the 47 countries currently affected within the next 11 years.

It is possible that historians will remember 2019 as the beginning of the end of cholera, but much depends on our efforts in the next few years. For starters, global health donors must step up to ensure that Gavi is fully funded in the next strategic investment period (2021-2025). This support is critical not only for ending cholera, but also for achieving all of our health-related goals. The routine immunization that Gavi provides is essential to building strong primary health-care systems and reaching universal coverage.

Second, cholera-affected countries must follow the lead of countries like Somalia, South Sudan, Zambia, Zimbabwe, and others. That means working with the World Health Organization on a cholera control plan to help governments unlock resources and receive technical assistance, including the oral cholera vaccine.

If we do not act now, WHO models show that climate change, urbanization, and population growth could increase cholera cases by 50% in the next 20 years.

There is much more to be done, including making major investments in sustainable water, sanitation, hygiene services, improved disease surveillance, and stronger health systems. Fortunately, the return on these investments will be immense. We can both eliminate cholera and make progress toward managing or eliminating a wide range of waterborne diseases, all of which is necessary for meeting the Sustainable Development Goals.

Where one lives should not determine whether one lives. But until we eliminate cholera deaths, that will be the tragic reality facing vulnerable communities across the Global South.

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Zaidi is Director of Vaccine Development, Surveillance, and Enteric and Diarrheal Diseases Programs at the Bill & Melinda Gates Foundation.