2019 can be beginning of the end for an ancient disease

Rescue workers retrieve a body after Cyclone Idai caused mudslides in Chimanimani, Zimbabwe, last March. Receding flood waters and rising temperatures increased the risk of a cholera outbreak, but an oral vaccine programme saved thousands of lives. Picture: KB Mpofu/

Cholera killed tens of thousands in Europe and the US in the 1800s, but is now mostly confined to developing countries. The goal is to have cut its death rate by 90% by 2030, according to Anita Zaidi.

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

What happened next is key: After Idai, 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 struck by natural disasters or afflicted by war have not been so fortunate. After an earthquake in 2010, Haiti experienced a protracted cholera outbreak that claimed thousands of lives and which jeopardised 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 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 organisations, is working to consign cholera to history.

In 2018, the GTFCC arranged the shipment of 17.4m 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 is thus a 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 public-private partnership, Gavi leverages financing for vaccination, reduces the cost of vaccines, and improves their delivery by supporting countries’ health systems.

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 10m 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 immunisation 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 (WHO) on a cholera-control plan to help governments unlock resources and receive technical assistance, including the oral cholera vaccine.

WHO models show that, if we do not act now, climate change, urbanisation, and population growth could increase cholera cases by 50% in the next 20 years. And that estimate does not account for the effects of climate change, urbanisation, and armed conflict, all of which could increase the severity and frequency of cholera outbreaks.

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 manage or eliminate a range of waterborne diseases, as part of 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.

Anita Zaidi is director of vaccine development, surveillance, and enteric and diarrheal diseases programmes at the Bill & Melinda Gates Foundation.

Copyright: Project Syndicate, 2019.

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