Cholera

Friday 22 February 2019 - Updated on Tuesday 5 November 2019
A disease to be tackled with multiple tools and strategies.
Cholera treatment center in Dala, Maiduguri, Nigeria
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Cholera treatment center in Dala, Maiduguri, Nigeria

Cholera is a toxic contagious enteric epidemic infection caused by Vibrio cholerae, serotype O1 or O139. It leads to acute watery diarrhea which can rapidly evolve to dehydration and death if left untreated. Most patients will recover with oral rehydration therapy; however, some patients will require rapid intravenous rehydration. The death rate can be less than 1% of cases with adequate treatment; however, this can be as high as 50% if cases are left untreated.


Cholera is transmitted via food or contaminated water and can be prevented by ensuring clean water, good sanitation, and effective hygiene. Cholera can also be controlled through vaccination. The cholera vaccine is an oral vaccine consisting of 2 doses that are administered two weeks apart. 

Cholera in endemic in south-east Asia and causes outbreaks in Africa and the Americas. An increased risk of cholera has been noted in parallel with the ever-increasing size of vulnerable populations living in unsanitary conditions, in slums were basic sanitation infrastructure is lacking, or due to a breakdown of the infrastructure as a result of war or a natural disaster. Cholera affects an estimated 3–5 million people worldwide and causes 28 800–130,000 deaths a year.

Mapping the burden of disease

Concentration the effort in the most affected places

Epicentre and the Johns Hopkins University have mapped the areas where cholera is most prevalent in Africa using modeling techniques1 . Results indicate that a concentrated effort in just 5% of all districts in Africa could reduce by half the disease burden in the continent. These findings are the linchpin of the Cholera Global Roadmap to 2030, which outlines the strategy to eliminate cholera transmission as well as providing the key rational for cholera control investment case. 

Global annual cholera incidence

Concentrating on the important strains

A complementary collaboration with Institut Pasteur, in which the whole genome sequencing of more than 1000 V. cholerae isolates has been analyzed, has shown that 7th pandemic strains have been introduced in Africa several times in the last 50 years from Southern-Asia. The circulation of strains can be monitored by observing the emergence of hotspots in neighbouring countries in Africa.  This makes it possible to anticipate the areas where such hotspots may appear and focus cholera control activities there. This helps prevent the reintroduction of new viruses.

Understanding outbreaks

Better estimates despite underreporting of cases

Retrospective morbidity and mortality studies conducted by Epicentre in Haiti demonstrated that the true number of cholera cases was much higher than recorded because remote villages are beyond the reach of health services3.   

Epicentre provides field epidemiology support to Médecins Sans Frontières (MSF) to describe cholera outbreaks in terms of time, place and person. Epicentre has developed as well models to better understand the cholera epidemics spread, as it has been recently the case in Yemen4. In addition, Epicentre has shown using spatial epidemiological methods that cholera spreads in clusters. 

Exploring suitable intervention strategies

Epicentre is exploring a better intervention strategy referred to as case-area target interventions, which can include WASH interventions, ring vaccination as well as distribution of antibiotics to household members. This intervention was piloted in 17 clusters in Juba in 2015; the results were encouraging but more work will be needed to confirm that this is an effective approach.

Diagnostics

Cholera treatment center in Yemen, 2017.
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Cholera treatment center in Yemen, 2017.

Optimizing detection for faster intervention

The cholera rapid diagnostic tests (RDTs) are useful to speed-up the detection, confirmation and notification of cholera epidemics. Reliable estimates of the sensitivity and the specificity of RDTs are essential. Several analytical epidemiological studies conducted in Zambia, South Sudan and DRC have covered this question both for Crystal VC and SD Bioline RDTs, using the direct method with stools and also an enrichment step in alkaline peptone water. 

Cholera vaccination

Chart showing the increase in the use of the cholera vaccine.
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Chart showing the increase in the use of the cholera vaccine.

Vaccination as a public health tool

Before 2012, cholera vaccine was almost exclusively a traveler’s vaccine and not a public health tool. In 2012, MSF conducted the first vaccination campaign in Guinea with Shanchol, a newly WHO prequalified vaccine, and analytical and descriptive epidemiological  studies conducted by Epicentre shown the feasibility of conducting such a campaign as well as the safety, efficacy, and acceptability of the vaccine5. This was an important step that contributed to the creation of the global cholera vaccine stockpile in 2013. Since then vaccination has become a standard tool in the fight against cholera. 
 

Vaccination in outbreaks

A timely response is essential during outbreaks, which is challenging to achieve with the currently recommended two-dose schedule. Epicentre is exploring the feasibility of controlling the outbreak spread by administering a single-dose. Results from our case-control studies conducted in Zambia and South Sudan indicated that the short term protection of single-dose is similar than two-dose protection in the short term6,7.

Hard-to-reach populations

Cholera response on and around lake Chilwa, Malawi, 2016.
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Cholera response on and around lake Chilwa, Malawi, 2016.

Access to vaccination and the administration of a two-dose schedule is particularly problematic for hard-to-reach populations, such as fishermen or displaced population living in conflict areas.  MSF has piloted administration of the 2nd dose either with the help of a community leader or at the individual level in such settings among fishermen in Malawi. This strategy has been made possible thanks to the high thermal-stability of the Shanchol vaccine , which has been  recently licensed for controlled-temperature-chain (CTC) use, meaning the vaccine can be safely used for 14 days stored up to 40C. Vaccine coverage surveys showed good acceptability among fishermen in Malawi and an analytical study showed the high effectiveness of this strategy to prevent cholera. 

Epicentre is part of the oral cholera vaccine working group at the Strategic Advisory Group of Experts (SAGE). Epicentre is also member of the Global Task Force for Cholera Control and actively participates in several working groups and chairs the cholera surveillance working group

Selected resources

Classification principale
07.06.2018

Modelling the cholera outbreak in Yemen - Camacho A - Video 2018

Classification principale
07.06.2018

Modelling the cholera outbreak in Yemen - Camacho A - Abstract 2018

Classification principale
07.06.2018

Cholera diseases burden and circulation of V. cholerae strains in Africa - Luquero F - Poster 2018

Classification principale
07.06.2018

Cholera spatial clustering and the use of case-area targeted interventions - Luquero F - Poster 2018

Classification principale
07.06.2018

Cholera vaccine protection: a meta-analysis from efficacy and effectiveness studies - Luquero F - Poster 2018

Classification principale
08.06.2017

Oral cholera vaccines: transforming old products into new solutions for neglected populations - Luquero F - Video 2017

Classification principale
08.06.2017

Oral cholera vaccines: transforming old products into new solutions for neglected populations - Luquero F - Abstract 2017

See all

Selected publications

Mapping the burden of cholera in sub-Saharan Africa and implications for control: an analysis of data across geographical scales.

Journal Reference: Lancet (London, England) 2018 05 12; 391(10133); 1908-1915. doi: 10.1016/S0140-6736(17)33050-7. Epub 2018 03 01

Cholera epidemic in Yemen, 2016-18: an analysis of surveillance data.

Journal Reference: The Lancet. Global health 2018 06 ; 6(6); e680-e690. doi: 10.1016/S2214-109X(18)30230-4. Epub 2018 05 03

Use of Vibrio cholerae vaccine in an outbreak in Guinea.

Journal Reference: The New England journal of medicine 2014 May 29; 370(22); 2111-20. doi: 10.1056/NEJMoa1312680. Epub 2014 06 10

Single-Dose Cholera Vaccine in Response to an Outbreak in Zambia.

Journal Reference: The New England journal of medicine 2018 02 08; 378(6); 577-579. doi: 10.1056/NEJMc1711583. Epub 2018 02 14
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References

1    Lessler J, Moore SM, Luquero FJ, McKay HS, Grais R, Henkens M, et al. Mapping the burden of cholera in sub-Saharan Africa and implications for control: an analysis of data across geographical scales. Lancet 2018. doi:10.1016/S0140-6736(17)33050-7.
2   Weill F-X, Domman D, Njamkepo E, Tarr C, Rauzier J, Fawal N, et al. Genomic history of the seventh pandemic of cholera in Africa. Science (80- ) 2017;358. doi:10.1126/science.aad5901.
3    Luquero FJ, Rondy M, Boncy J, Munger A, Mekaoui H, Rymshaw E, et al. Mortality rates during cholera Epidemic, Haiti, 2010-2011. Emerg Infect Dis 2016;22. doi:10.3201/eid2203.141970.
4    Camacho A, Bouhenia M, Alyusfi R, Alkohlani A, Naji MAM, de Radiguès X, et al. Cholera epidemic in Yemen, 2016–18: an analysis of surveillance data. Lancet Glob Heal 2018;0. doi:10.1016/S2214-109X(18)30230-4.
5   Luquero FJ, Grout L, Ciglenecki I, Sakoba K, Traore B, Heile M, et al. Use of Vibrio cholerae vaccine in an outbreak in Guinea. N Engl J Med 2014;370. doi:10.1056/NEJMoa1312680.
6    Azman AS, Parker LA, Rumunu J, Tadesse F, Grandesso F, Deng LL, et al. Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study. Lancet Glob Heal 2016;4:e856–63. doi:10.1016/S2214-109X(16)30211-X.
7    Ferreras E, Chizema-Kawesha E, Blake A, Chewe O, Mwaba J, Zulu G, et al. Single-Dose Cholera Vaccine in Response to an Outbreak in Zambia. N Engl J Med 2018;378. doi:10.1056/NEJMc1711583.