by Tharien van Eck, AWC Antwerp and Health Team Co-Chair
What is cholera?
It is an acute diarrheal infection caused by the intake of food or water contaminated with the bacterium Vibrio cholerae. Cholera remains a global threat to public health and an indicator of inequality and lack of social development.
A few general facts about the disease
-
Most people infected with cholera will make a full recovery with the use of oral rehydration solution.
-
Roadmap 2030 is a global strategy with a target to reduce cholera deaths by 90% by 2030, an aggressive target given the annual caseload of 1.3 to 4.0 million cases of cholera and 21,000 to 143,000 deaths worldwide due to the disease. Why? Firstly, cholera can kill individuals within hours in severe cases if left untreated, and secondly, there are significant challenges regarding the inadequate distribution and availability of the vaccine.
-
Access to safe drinking water and proper sanitation are critical aspects in preventing and controlling the transmission of cholera and other waterborne diseases.
Where does cholera come from?
The original reservoir of cholera was the Ganges Delta in India. It spread across the world during the nineteenth century, and has since killed millions of people in at least six pandemics. It is said that we currently are in the seventh pandemic, which started in South Asia in 1961, reached Africa in 1971 and the Americas in 1991. Cholera is now endemic in many countries.
There is a vaccine. But why is it still such a public health issue?
The answer to this question is easy, but perhaps uncomfortable! There are indeed three vaccines (Dukoral®, Shanchol™, and Euvichol-Plus®), but all three only offer full protection after two doses.
Dukoral requires that it is given with a buffer solution, which is typically 150 ml clean water. It must be repeated between one and no more than six weeks. It offers protection for two years only. Children require three doses.
The other two vaccinations, made by different manufacturers, do not require a buffer solution. They are still double-dose vaccines, but can be repeated after two weeks. Both offer protection for three years.
Therefore, access to vaccines, limited duration of protection, and storage in a controlled temperature chain (or full cold chain) are important aspects to be aware of.
Why the need for this article on cholera?
Cholera is a public health issue of concern in Kenya, the country in which Awesome Blossoms, the current environmental Target Project, is located. The country has recorded more than 11,872 cases and 196 deaths (data through August 2023) since the onset of the current cholera outbreak began in October 2022. However, it has now spread to the south, with the highest reported mortality rates in Nairobi, Garissa, Tana River and Wajir counties.
A report issued by the global vaccine alliance GAVI on August 28, 2023, is entitled “Kenya cholera vaccine campaign smashes target, but climate change boosts risk.” There was an important cholera vaccination drive in early August 2023, targeting 1.59 million people in eight high-risk counties. The drive was successful, but the outbreak continues to jump from county to county, making control very difficult. To date, the outbreak has affected 26 counties, about half of the country. The outbreak is not controlled yet, and people should continue to take all the required precautions.
Kenya's Deputy General in the Health Ministry recently stated, “Cholera is endemic in Kenya, with outbreaks occurring during different periods, also influenced by climate change.” He continued, “Most cases are asymptomatic, [but] affected persons are infectious during the acute stage of the disease up to days after recovery, with deaths occurring [in some cases] within hours after infection if not treated properly.”
How to protect yourself as a visitor?
An important question for you may be the availability of cholera vaccinations in Europe and other countries – and where can you find them. I found an FDA document dated May 2021 that stated: “Emergent Travel Health, Inc. informed the FDA that they had decided to temporarily discontinue the manufacture and distribution of Vaxchora® in the United States due to a significant reduction of international travel caused by the COVID-19 pandemic.” The Paul-Ehrlich-Institut reported that “The cholera vaccines Dukoral and Vaxchora are expected to be unavailable until 31 March 2023 (Dukoral) and 27 March 2023 (Vaxchora) respectively.” But are they available now, and could I, as a traveler, access them?
I checked the Tropical Institute website (a world renowned institute on tropical and other infectious diseases, located in Antwerp, Belgium) to determine the awareness about the diseases and the availability of the cholera vaccine when traveling to Kenya or other affected countries. There was an immediate warning about a measles outbreak, but nothing about cholera. The site had a list of important health risks for traveling in Kenya, but no mention of cholera. I looked under the suggested/required vaccination list and did not see a word about the cholera vaccine. I did a search under the keyword “cholera,” and once again, no information.
It is unclear as to where the vaccine is available. So, the general travel precautions continue to apply: drink only bottled water, brush your teeth with bottled water, eat only cooked food, nothing from street markets or vendors, and wash your hands as much as possible. And keep hand sanitizer close by!
In closing, I looked at information on numerous websites and published articles while researching this article, and the heading that was the biggest concern to me was “The World Is Not Prepared for Another Cholera Wave.”(*) A single case of cholera was detected in March 2022 in southern Malawi, and a year later, there was a multi-country outbreak!
(*) This article describes the impact of environmental disasters on vaccination, a must-read if you are interested in public health.
Resources:
- Cholera | WHO
- Kenya | Wanda
- The World Is Not Prepared for Another Cholera Wave | Gavi, the Vaccine Alliance
- CBER-Regulated Products: Resolved Shortages | FDA
- Controlled temperature chain (CTC)
Illustration by Tharien van Eck