Winning the Fight Against Cholera

By Frew Benson

JOHANNESBURG – Beginning in 2017, Yemen suffered the largest and fastest-spreading cholera outbreak in modern history. Thousands of new cases were reported daily, more than half of them children. And Yemen was not alone: that year, more than 1.2 million people contracted cholera in 34 countries, and 5,654 died. Given that cholera is preventable and treatable, this never should have happened. Fortunately, there is reason to hope that it won’t happen again.

Cholera is a diarrheal disease caused by consuming water or food contaminated by the bacterium Vibrio cholerae. It spreads rapidly in areas where sewage and drinking water supplies are inadequately treated, making it largely a disease of the poorest and most vulnerable – the very young, the very old, the malnourished. and the displaced. Without treatment, cholera can kill within hours. Though the treatment – basic rehydration therapy – is simple, society’s most marginalized members are unlikely to have access to it.

But for the last three years, the Global Task Force on Cholera Control – a partnership of over 50 organizations – has been working to eliminate cholera as a public health threat. As chair of the GTFCC, I proudly support our global roadmap, which aims to eradicate the disease in 20 countries and achieve a 90% reduction in associated deaths by 2030, both by expanding the use of the oral cholera vaccine and by improving water, sanitation, and hygiene (WASH) services.

In accordance with the roadmap, GTFCC partners set to work in late 2017 to establish a support system for cholera-affected countries. By scaling up technical assistance and offering tools and recommendations to support the development of national cholera-control plans, the GTFCC has contributed to enabling national governments to take the lead in implementation.

In Haiti, for example, the Ministry of Public Health and Population deployed rapid-response teams to affected areas, where they disinfected houses, supplied hygiene materials, and provided health education. In 2018, the country recorded its lowest number of cholera cases since its epidemic began in 2010. Haiti has not confirmed a case of cholera in well over a year, a testament to the power of strong disease surveillance and WASH services.

Moreover, with the support of GTFCC partners, nine affected countries delivered 10.5 million doses of the oral cholera vaccine in 2017. Within a year, the World Health Organization reported, cholera cases plummeted by 60%, to 499,447 in 34 countries, with 2,990 deaths. While the precise role the vaccine played in this drop is not yet fully documented, it is clearly an important part of the solution.

Cholera-affected countries have continued to lead this fight. Over the last three years, with the backing of Gavi, the Vaccine Alliance, they have delivered more than 50 million doses of the oral cholera vaccine. Cholera outbreaks did occur in Burundi, the Democratic Republic of the Congo, Ethiopia, Mozambique, and Sudan. But the affected countries were able to respond more effectively, thanks partly to the GTFCC’s support.

Efforts are also underway to move beyond responding to outbreaks. Efforts to strengthen long-term cholera control and eradication are underway in Bangladesh, Zambia, and Zimbabwe. The power of preemptive action was demonstrated in Mozambique last year: after typhoons raised the risk of an outbreak, the government quickly launched a vaccination campaign and successfully prevented the disease from taking hold.

But the oral cholera vaccine – which is effective for only three years – is not a long-term solution. Instead, it provides a bridge between outbreak response and long-term disease control. With climate change, urbanization, and population growth creating an ideal breeding ground for cholera, we need more countries to cross that bridge – and soon.

That means continuing to work with manufacturers to expand vaccine access. The successful $8.8 billion refunding of Gavi in June will go a long way toward advancing this goal. It also means increasing investment in strengthening WASH services, which can protect populations from cholera long after the vaccine wears off.

Moreover, to achieve our global roadmap goals in a fast-changing global landscape, countries need flexible, well-resourced support mechanisms. That is why the GTFCC secretariat is establishing the Country Support Platform, which will complement the WHO cholera program.

The Country Support Platform will be responsible for ensuring the effective organization of cholera-control resources and supporting the countries and communities most in need. This will include building capacity for surveillance, reporting, and analysis. After all, we can’t fight cholera unless we know precisely where it is occurring.

To this end, we need to end the stigma around cholera. Embargoes on the movement of people and goods are not only ineffective in preventing the spread of the disease; they also make governments reluctant to report outbreaks, for fear of the economic fallout. If countries were assured that they would receive support, rather than punishment, they would be able to take a proactive approach to prevention. The Country Support Platform’s goal is to reinforce countries’ ability to stem outbreaks before they begin.

Fortunately, many countries – such as Ethiopia, Kenya, and Sudan – have committed to developing multisectoral cholera-control plans, with assistance from the GTFCC. For this to work, effective cross-border communication and cooperation among policymakers, health workers, WASH service providers, and local communities is essential. The Country Support Platform will facilitate such efforts, serving as a hub for the GTFCC’s work and helping to foster effective collaboration.

The COVID-19 pandemic has placed serious strain on health-care systems worldwide. The last thing countries need is also to face cholera outbreaks. The GTFCC – and the new Country Support Platform – stands ready to help ensure that they don’t.

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Benson is Chief Director of the National Department of Health of South Africa and Chair of the Global Task Force on Cholera Control.