A joint plan has been announced by African leaders to combat the centuries-old disease that has seen cases doubling on the continent over the past three years, this year alone causing nearly 5 000 deaths.
“Action is needed, not tomorrow, but now,” said Yap Boum of the Africa Centres for Disease Control and Prevention, talking about cholera.
NPR reports that there have been more than 230 000 cases this year across 23 countries, up from 15 affected countries in 2022, according to Africa CDC.
The disease is easily treatable, yet deadly. It can kill someone in a matter of hours if good medical care is not provided promptly.
Last week, the rising numbers brought African leaders to Lusaka, Zambia, where last week they announced an emergency plan and presidential task force to combat the severe diarrhoeal infection. The new plan is a joint effort between Africa CDC and the World Health Organisation.
WHO, in a situation report on cholera last week, wrote that the situation “continues to deteriorate, driven by conflict and poverty”. It said cholera is “resurging in a number of countries, including some that had not reported substantial case numbers in years, like Chad and the Republic of Congo”.
Particularly worrisome is that in half a dozen countries, more than 1% of patients are dying of cholera, “indicating serious gaps in case management and delayed access to care”, according to the report.
The infection comes from consuming water or food contaminated by the bacterium Vibrio cholerae.
Boum says an important part of the new initiative is that it is happening at presidential level, allowing coordination across countries as well as across multiple ministries within a country, such as those involved in water infrastructure.
“The actual driver, which is access to clean water, is not the mandate of the Ministry of Health. So what is changing now is to bring the issue of cholera at the highest level, at the presidential level.”
With an estimated budget of $231m, the emergency plan is focused on the next six months and includes more than 350 cholera treatment centres and hundreds of outpatient treatment locations.
An estimated 10m oral cholera vaccine doses will be needed, and the costs will be covered by donations. Boum said one of the mandates of the task force is to mobilise resources for this effort.
The long-term goal is to eliminate cholera as a major public health issue by 2030 – a lofty aim for an ancient infection.
Ancient history
Cholera’s origins are in India, where it has been in the Ganges delta “from time immemorial”, according to Dr David Sack, a Professor of International Health at the Johns Hopkins Bloomberg School of Public Health, who has spent much of his career studying the disease.
Cholera began spreading from India throughout the West in the early 1800s with more global trade and travel by ships. Soon there were cases cropping up all the way from Russia and Western Europe to American cities.
“It affected large parts of the world,” Sack said. With a fatality rate of about 50% if untreated, it killed millions of people as it spread across the globe.
“At that time, we didn’t know what caused it,” he said, “or how to treat it.”
Theories about the cause of the illness were plentiful, but all had a common thread. There appeared to be a link between cholera and overcrowded urban areas.
Finally, in the 1850s, an English doctor named John Snow became a legend of public health for figuring out that an outbreak in the Soho neighbourhood of London was linked to a single drinking water source.
Snow is credited with stopping the raging outbreak – which claimed 10 000 lives across London – by removing the handle from the local water pump.
He argued correctly that water contaminated with sewage was spreading the illness from one resident to another. But he still didn’t know exactly what the water was contaminated with: at the time, the pathogen that caused cholera hadn’t yet been discovered.
He theorised that it might be tiny parasites or germs or some “poison” able to reproduce in the water.
Around the same time, Italian scientist Filippo Pacini identified the bacteria that cause cholera. But his discovery wouldn’t be widely accepted for decades – and in the meantime, millions more died.
Fast killer
One thing that makes cholera notorious is its speed. The severe gastrointestinal disease can trigger so much diarrhoea and vomiting that patients can rapidly become dehydrated. They can lose so much fluid that their internal organs shut down. This can happen over the course of days or just hours.
The WHO says there are 1.3m to 4m cases and between 21 000 and 143 000 deaths from cholera each year.
Cases crop up throughout the world, particularly when a crisis or conflict strikes and clean drinking water is not available. And Africa has been particularly hard hit, currently accounting for 82% of global cases and nearly 94% of cholera-related deaths, according to Africa CDC.
Climate and conflict
There are two main types of cholera outbreaks: those that circulate within countries where outbreaks happen regularly and those that begin spiralling out of control during a crisis, such as a conflict or natural disaster like a flood or an earthquake.
In war zones like Ukraine, the breakdown of water, sanitation and health infrastructure means that the introduction of cholera can spread rapidly – and disastrously.
During its ongoing civil war, for example, Yemen has had the worst cholera outbreak in recorded history with more than 2.5m cases and around 4 000 deaths, according to the United Nations’ International Organisation for Migration.
In Chad, the cholera outbreak is driven by the conflict in neighbouring Sudan.
“You have the mass refugee influx, leading to overcrowding [in] the camp with unsafe water and sanitation,” said Boum.
“Whether in Ethiopia, in Sudan, in Chad, you always see … the humanitarian crisis is fuelling those outbreaks. There is no health without peace.”
Souped-up sugar water
The good news about cholera is that treatment is actually simple: it’s rehydration.
“Patients with cholera should never die,” Sack said. “If they get to a treatment centre in time, if they still have a breath, we can save their life.”
Treatment consists of simply keeping the person hydrated. If they are capable of drinking, they can be treated with oral rehydration fluids – basically souped-up sugar water. This strategy works in about 80% of cases. In more severe cases, the patient may need to be given fluids intravenously alongside antibiotics.
If cholera is treated quickly, within hours, before a patient’s health declines, fewer than 1% of them die.
Cholera is also fairly easy to identify. Patients have distinctive stool that is yellowish or whitish, while rapid tests can check for suspected cases in individuals even before a laboratory confirms an outbreak.
There are also three vaccines that can be administered in areas where cholera occurs regularly or when an epidemic begins to take root.
Between 1997 and 2012 just 1.5m doses of the vaccines were used worldwide, according to WHO. In 2017, that number jumped to more than 10m doses. And in 2023, some 35m doses were used, says Gavi, the Vaccine Alliance.
Yet the vaccine supply is sometimes inadequate, mainly because it has not been a funding priority for other countries.
“We don’t have enough for every place,” Sack saids. And it is difficult to venture into conflict zones, like the one in Ukraine, to vaccinate people.
In 2013, however, Gavi established a cholera vaccine stockpile. Any country can request to use these reserves if it’s experiencing a cholera outbreak.
“Cholera is certainly the stockpile that’s used the most,” said Allyson Russell, senior programme manager for outbreaks and global health security at Gavi. This year, as of July, “we’ve sent 30m doses of cholera emergency vaccines to 12 countries”.
The vaccines cost less than $5 a dose to produce and deliver, according to Africa CDC. That means that with enough resources, everyone at risk could be vaccinated.
The challenge of providing people with safe water and good sanitation is far more costly but also key to preventing outbreaks.
Without it, cholera persists even after an epidemic begins to slow.
NPR article – An ancient disease makes yet another comeback (Open access)
See more from MedicalBrief archives:
Long-term strategy vital to combat cholera threat in Africa
Cholera vaccine shortage a global crisis
WHO shifts to one-dose cholera jab as outbreaks increase, stocks dwindle