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The Lancet
Oct 07, 2017 Volume 390 Number 10103 p1623-1714   e24
http://www.thelancet.com/journals/lancet/issue/current
Editorial
Cholera: ending a 50-year pandemic
The Lancet
Published: 07 October 2017

The global annual cholera burden is estimated at around 2·9 million cases per year, resulting in 95 000 deaths. In 2017, these estimates could be far exceeded due to a number of devastating outbreaks, including those in Yemen and northern Nigeria. So far this year, 750 000 suspected cases, causing over 2000 deaths, have occurred in Yemen alone. Currently, there is concern about the risk of a cholera epidemic among Rohingya refugees in the Cox’s Bazar region of Bangladesh. In response to this public health threat, the Global Task Force on Cholera Control (GTFCC), has brought together representatives from cholera-affected countries, donors, and technical experts to develop a Global Roadmap to 2030. Published on Oct 3, the document describes a multisectoral strategy that could reduce cholera deaths by 90% and eliminate the disease from a further 20 countries by 2030.

As John Clemens and colleagues describe in a Seminar published recently in The Lancet, cholera is an ancient disease. Endemic in the Ganges river basin, it has caused a series of pandemics since 1817, the most devastating being the seventh pandemic, which began in 1961 and is ongoing. Cholera is a disease steeped in medical history—it was during the third pandemic that John Snow plotted his famous map of Broad Street, and during the fifth epidemic, that Robert Koch sought to identify the causative agent. Spread by the faeco-oral route, the disease affects poor people and the most vulnerable. Cholera is endemic in 47 countries, particularly in areas where the water, sanitation and hygiene (WASH) infrastructure is poor. In these areas, children are particularly at risk. Epidemics occur both within and outside of endemic areas, often amid humanitarian crises, when WASH infrastructure breaks down or is overwhelmed. In situations where the population lacks immunity, a wider age range is affected, often with more severe clinical manifestations. Currently the worldwide cholera burden is high. 60–70% of cholera cases and deaths occur in endemic areas of Africa, which could increase as urbanisation, particularly the growth of slums, places increasing numbers at risk.

Fluid resuscitation as the core of cholera treatment is well established, but recent developments in disease prevention strategies underlie the GTFCC’s roadmap. Improvements in WASH systems can eliminate cholera, but although the rate of return on investment is good, these are initially expensive, and the slow expansion of WASH provision has failed to tackle the burden of cholera and other water-borne diarrhoeal diseases. The pivotal change in cholera control has been the development of oral cholera vaccines (OCV), underpinned by an improved understanding of the mechanism of cholera immunity. In a series of landmark research developments over the past 10 years, the efficacy, safety, acceptability, and feasibility of these vaccines have been demonstrated. The creation of a growing global OCV stockpile by WHO, with long-term funding support from Gavi, signalled the step-change in cholera prevention strategies and, since 2013, 13 million vaccine doses have been deployed, mostly in the emergency control of epidemics.

The novelty of the GTFCC eradication strategy is based on three key axes. First, the emphasis on rapid response to outbreaks: controlling epidemics through community engagement, improved early warning surveillance, and the rapid delivery of cholera control kits, OCV, and WASH supplies. Second, the strategy implements a multisectoral approach in hotspots of endemic cholera. OCV programmes will be used as a bridge, immediately reducing disease burden and mortality while long-term solutions are developed: sustainable WASH infrastructure, strengthened health systems able to anticipate epidemics, and strong community engagement required to stop transmission. The third axis is the coordination of operational support, local and global resourcing, and technical expertise delivered by GTFCC. Over the next 18 months, the task force will support six to eight countries to develop cholera control plans, develop an investment case on cholera, and create operational guidance on integrated prevention strategies ahead of a review meeting planned in 2019.

The bold vision of the Global Roadmap is welcome but the challenges that lie ahead should not be underestimated, Paul Spiegel, director of the Center for Humanitarian Health at Johns Hopkins University told The Lancet. Ending cholera depends both on successful delivery of the prevention strategies on the ground and mitigating risks to the Global Roadmap at a high-level (securing financing, ensuring vaccine availability, and galvanising political will). The technical ability to control cholera is within our capabilities. After 50 years, could the tide be finally turning on the seventh pandemic?

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UNICEF’s preventive plan to mitigate the risk of Acute Water Diarrhoea (AWD) and Cholera among Rohingya Refugees
UNICEF’s preventive plan to mitigate the risk of Acute Water Diarrhoea (AWD) and Cholera among Rohingya Refugees
Remarks attributable to Maya Vandenant, Chief of Health, UNICEF Bangladesh
GENEVA/DHAKA, Bangladesh 6 October 2017 – This is a situation update from Maya Vandenant, Chief of Health, UNICEF Bangladesh, – to whom quoted text may be attributed – for today’s press briefing at the Palais des Nations in Geneva.
Key Facts
:: 515,000 new Rohingya arrivals into Cox’s Bazar, Bangladesh since 25th August;
:: 225,000 of new arrivals are living in new spontaneous settlements with very limited Water, Sanitation and Hygiene (WASH) infrastructure due to an absence of planning;
:: 60% of new arrivals are children and 30% are children under 5 years old;
:: In the last week, 5011 cases of diarrhoea have been reported;
:: Since 25th August 2017, over 300 tube wells and 3,000 latrines have been constructed to improve WASH within both the extended existing makeshift settlements and the new spontaneous settlements;
:: UNICEF has launched a response plan to prevent an outbreak of Acute Watery Diarrhoea and Cholera;
:: There are high levels of severe malnutrition amongst child refugees which exacerbates the risks associated with an outbreak of acute watery diarrhoea and cholera.
“What we are seeing is that people are exhausted and children are at a heightened risk of diseases. There are real risks of acute watery diarrhoea and cholera outbreaks. We are very concerned, and therefore, we are mounting an urgent response across the health sector.
“Planning of the extension camps is largely absent and there is no infrastructure in terms of ensuring good sanitation and drainage. We see that after the rains, water flushes through the camps everywhere, including the toilets. Additionally, the camps are now subject to high population densities. These factors increase the risk of disease outbreak and transmission.

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Editor’s Note:
Repeating from last week’s edition:

900,000 vaccines ‘en route’ to Cox’s Bazar to prevent cholera
Oral cholera vaccine will protect Rohingya refugees seeking shelter in Bangladesh as well as the resident population
Cox’s Bazar, Bangladesh, 29 September 2017 – The International Coordinating Group (ICG) on Vaccine Provision will release 900,000 doses of the Oral Cholera Vaccine (OCV) from the global stockpile to prevent the spread of cholera among recently arrived vulnerable populations and host communities in areas around Cox’s Bazar.
The Government of Bangladesh made the request to the ICG on 27 September, and the approval was granted in 24 hours by the coordinating mechanism that brings together WHO, UNICEF, Médecins Sans Frontières (MSF), and the International Federation of the Red Cross (IFRC).
ICG partners – with support from Gavi, the Vaccine Alliance – will deliver 900,000 doses of Oral Cholera Vaccine to Bangladesh within two weeks for an immunisation campaign due to start in October.