COMMITTEE: WORLD HEALTH ORGANIZATION
AGENDA ITEM: Eradicating the presence of cholera in Africa due to lack of accessibility to clean water.
Cholera is an acute diarrhoeal disease that can kill within hours if left untreated.
Each year 1.3 to 4.0 million cases of the illness occur around the world, leading to between 21 000 to 143 000 deaths. About two-thirds of these are in developing countries, mostly in sub-Saharan Africa.
Cholera is referred to as a disease of poverty because of the lack of social development in the areas in which it occurs.
The constant threat of natural catastrophes such as flooding and man made ones including civil unrest, make the management and prevention of cholera a huge challenge in most of Africa.
Several conditions on the continent make it fertile ground for the emergence and rapid spread of cholera. These include:
- Inadequate access to clean water and sanitation facilities, especially in peri-urban slums, where basic infrastructure isn’t available.
- Camps for internally displaced persons or refugees, where minimum requirements of clean water and sanitation have not been met. Crowded camps are fertile ground for a cholera outbreak.
- Other humanitarian crises including flooding and earthquakes, civil unrest or war that causes disruption of water and sanitation systems.
What has been the progress of cholera outbreak responses in Africa?
But generally the lack of comprehensive programs for improvement of general public health especially for vulnerable populations like refugees and informal settlement residents is a challenge.
African countries have not achieved nearly enough. This is true when it comes to detecting primary cases and then isolating and treating them to arrest further transmission. This is particularly the case in refugee camps.
Very often efforts to provide clean drinking water, safe disposal of sewage and improved housing are poorly coordinated, halfhearted and mediocre.
The increase in population especially in urban informal settlements has been exponential over the last two decades posing a major challenge for public health as more people flock to the cities in search of jobs.
On top of this a lack of political maturity in many African countries as well as greed for political power has led to civil unrest and chaos which in turn has resulted in internal displacements of huge populations.
There are recommended vaccines that can minimise the spread of cholera. But they are rarely used as for most governments this not a priority.
Cost matters! Unlike cholera vaccine, most of the Expanded Programme on Immunisation vaccines are usually provided free through the GAVI initiative. Hence my suggestion that the cholera vaccine be made part of EPI initiative for endemic areas/regions.
Are there reasons for optimism?
Vaccines can prevent up to 65% of vulnerable populations from getting cholera. This also keeps away other food borne diseases such as typhoid, dysentery, E. coli and diarrhoea.
- Cholera is an acute diarrhoeal disease that can kill within hours if left untreated.
- Researchers have estimated that each year there are 1.3 to 4.0 million cases of cholera, and 21 000 to 143 000 deaths worldwide due to cholera1.
- Most of those infected will have no or mild symptoms, and can be successfully treated with oral rehydration solution.
- Severe cases will need rapid treatment with intravenous fluids and antibiotics.
- Provision of safe water and sanitation is critical to control the transmission of cholera and other waterborne diseases.
- Oral cholera vaccines are an additional way to control cholera, but should not replace conventional control measures.
- Safe oral cholera vaccines should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in areas known to be high risk for cholera.
Cholera transmission is closely linked to inadequate access to clean water and sanitation facilities. Typical at-risk areas include peri-urban slums, where basic infrastructure is not available, as well as camps for internally displaced persons or refugees, where minimum requirements of clean water and sanitation have not been met.
The consequences of a humanitarian crisis – such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission, should the bacteria be present or introduced. Uninfected dead bodies have never been reported as the source of epidemics.
The number of cholera cases reported to WHO has continued to be high over the last few years. During 2015,172 454 cases were notified from 42 countries, including 1304 deaths (4). The discrepancy between these figures and the estimated burden of the disease is due to the fact that many cases are not recorded due to limitations in surveillance systems and fear of impact on trade and tourism.
The long-term solution for cholera control (which benefits all diseases spread by the fecal-oral route) lies in economic development and universal access to safe drinking water and adequate sanitation. These measures prevent both epidemic and endemic cholera.
Actions targeting environmental conditions include:
- the development of piped water systems with water treatment facilities (chlorination)
- interventions at the household level (water filtration, chemical or solar disinfection of water, safe water storage)
- the construction of systems for safe sewage disposal, including latrines.
Many of these interventions require substantial long-term investments and continued maintenance, making them difficult to fund and sustain by less developed countries where the interventions are most needed.
In 2014 the Global Task Force on Cholera Control (GTFCC), with its Secretariat based at WHO, was revitalised. The GTFCC is a network of more than 50 partners active in cholera control globally, including academic institutions, non-governmental organisations and United National agencies. Through the GTFCC and with support from donors, WHO works to:
- promote the design and implementation of global strategies to contribute to capacity development for cholera prevention and control globally;
- provide a forum for technical exchange, coordination, and cooperation on cholera-related activities to strengthen country capacity to prevent and control cholera;
- support countries for the implementation of effective cholera control strategies and monitoring of progress;
- disseminate technical guidelines and operational manuals;
- support the development of a research agenda with emphasis on evaluating innovative approaches to cholera prevention and control in affected countries; and
- increase the visibility of cholera as an important global public health problem through the dissemination of information about cholera prevention and control, and conducting advocacy and resource mobilization activities to support cholera prevention and control at national, regional, and global levels.
Cholera is an acute enteric infection caused by the ingestion of bacterium Vibrio cholerae present in faecally contaminated water or food. Primarily linked to insufficient access to safe water and proper sanitation, its impact can be even more dramatic in areas where basic environmental infrastructures are disrupted or have been destroyed. Countries facing complex emergencies are particularly vulnerable to cholera outbreaks. Massive displacement of IDPs or refugees to overcrowded settings, where the provision of potable water and sanitation is challenging, constitutes also a risk factor. In consequence, it is of paramount importance to be able to rely on accurate surveillance data to monitor the evolution of the outbreak and to put in place adequate intervention measures Coordination of the different sectors involved is essential, and WHO calls for the cooperation of all to limit the effect of cholera on populations.
- Cholera is characterized in its most severe form by a sudden onset of acute watery diarrhoea that can lead to death by severe dehydration. The extremely short incubation period – two hours to five days – enhances the potentially explosive pattern of outbreaks, as the number of cases can rise very quickly. About 75% of people infected with cholera do not develop any symptoms. However, the pathogens stay in their faeces for 7 to 14 days and are shed back into the environment, possibly infecting other individuals. Cholera is an extremely virulent disease that affects both children and adults. Unlike other diarrhoeal diseases, it can kill healthy adults within hours. Individuals with lower immunity, such as malnourished children or people living with HIV, are at greater risk of death if infected by cholera.
The economic investment case for increasing access to water, sanitation, and hygiene
The economic benefits arising from increased coverage of WASH are vast, elevating the importance of achieving WASH targets 6.1 and 6.2 of the SDGs, which call for universal access to safe water, and sanitation and hygiene, respectively.
1. Inadequate sanitation and water supply makes countries poorer: The economic costs of not investing in water and sanitation are very significant. For 26 countries spread across South Asia, Southeast Asia and Africa, with a population in 2006 of 2.3 billion people, economic losses caused by poor sanitation alone amounted to about US $80 billion annually, or US $35 per person per year19.
2. The economic benefits of both water supply and sanitation indicate excellent value for money: Attaining universal water supply and sanitation will have total annual benefits of US $220 billion. An update provided by WHO in 2012 showed that combined water supply and sanitation interventions have a US $4.30 return for every dollar spent20.
3. The benefits from investments in water and sanitation are underestimated: Returns would be much higher than currently estimated if all benefits from investments in water supply and sanitation services were to be included, such as exports, tourism, waste reuse, water quality savings, and social benefits (such as gender equity, safety, and dignity). However, no studies include all the potential benefits due to lack of underlying data, challenges in attributing broader changes over time to improved water and sanitation (i.e. determination of causality), as well as difficulties in converting social impacts to monetary values.
It has been 150 years since the world’s high-income countries achieved control of cholera, thanks to the implementation of safe piped water, sewerage systems, and basic hygiene principles. However, the world’s poorest remain at risk: at the beginning of the 21st century, millions of people still lack access to safe drinking water and basic sanitation facilities. The burden of cholera remains high in those groups and stands to worsen if we fail to act. Further conflict, climate change, urbanization, and population growth will create an increased risk of cholera in the coming years. Now is the time to accelerate action against cholera at country and global levels. The tools and technologies we need to control cholera are already well known and readily available to us. Now is the time for technical partners, donors, and countries to commit to achieving full implementation of an integrated cholera control strategy—using modern methods to tackle an old disease and save lives.