Global & Disaster Medicine

Archive for the ‘Cholera’ Category

Zimbabwe: An outbreak of cholera has so far killed 25 people, mostly in the capital, Harare.


“……The current outbreak began on 6 September after water wells were contaminated with sewage in Harare.

Tests found the presence of cholera and typhoid-causing bacteria which has so far infected over 3,000 people, Health Minister Obadiah Moyo told reporters on Thursday.

According to the World Health Organization (WHO), patients were not responding to first-line antibiotics……The cholera outbreak can be traced to Harare city council’s struggle to supply water to some suburbs for more than a decade, forcing residents to rely on water from open wells and community boreholes……”


WHO in Zimbabwe: 2,000 suspected cholera cases have been reported, 58 of them confirmed and 24 fatal.


Harare/Brazzaville 13 September 2018 – The World Health Organization (WHO) is scaling up its response to an outbreak of cholera in Zimbabwe, which is expanding quickly in Harare, the country’s capital with a population of more than two million people.

Cholera is an acute waterborne diarrhoeal disease that is preventable if people have access to safe water and sanitation and practice good hygiene, but can kill within hours if left untreated. Authorities report that the outbreak began on 1 September in Harare and as of that date to 11 September, the Ministry of Health and Child Care reports that there have been nearly 2000 suspected cholera cases, including 58 confirmed cases and 24 deaths.

Glenview, a high density suburb of Harare with an active trading area and a highly mobile population is at the epicentre of the outbreak. The area is vulnerable to cholera because of inadequate supplies of safe piped water, which has led people to use alternative unsafe supplies such as wells and boreholes. Cases that are linked to the epicenter in Harare have been confirmed in 5 additional provinces.

The Government of Zimbabwe has declared a state of emergency and is working with international partners to rapidly expand recommended cholera response actions, including increasing access to clean and safe water in the most affected communities and decommissioning contaminated water supplies. Authorities and partners are also intensifying health education to ensure that suspect cases seek care immediately and establishing cholera treatment centres closer to affected communities.

“When cholera strikes a major metropolis such as Harare, we need to work fast to stop the spread of the disease before it gets out of control,” said Dr Matshidiso Moeti, the WHO Regional Director for Africa. “WHO is working closely with the national authorities and partners to urgently respond to this outbreak.”

WHO is supporting the Ministry of Health and Child Care to fight the outbreak by strengthening the coordination of the response and mobilizing national and international health experts to form a cholera surge team. In collaboration with health authorities and partners, WHO experts are helping to track down cases, providing technical support to laboratories and improving diagnostics and strengthening infection and prevention control in communities and health facilities. In addition to such measures and efforts to improve water and sanitation, the government is assessing the benefits of conducting an oral cholera vaccine (OCV) campaign and WHO is deploying an expert in OCV campaigns to Harare.

WHO is providing cholera kits which contain oral rehydration solution, intravenous fluids and antibiotics to cholera treatment centres.

Zimbabwe has experienced frequent outbreaks of cholera, with the largest outbreak occurring from August 2008 to May 2009 and claiming more than 4000 lives.

Cholera is a major public health problem in the African region and just two weeks ago Health Ministers from the region committed to ending cholera outbreaks by 2030 by implementing key strategies. Forty-seven African countries adopted the Regional Framework for the Implementation of the Global Strategy for Cholera Prevention and Control at the 68th session of WHO’s Regional Committee for Africa.

November 18, 2015–June 6, 2016: The largest cholera outbreak (1,797 cases; attack rate 5.1 per 1,000) in the history of Dadaab refugee camp in Kenya occurred.


Golicha Q, Shetty S, Nasiblov O, et al. Cholera Outbreak in Dadaab Refugee Camp, Kenya — November 2015–June 2016. MMWR Morb Mortal Wkly Rep 2018;67:958–961. DOI:

“…..During November 18, 2015–June 6, 2016, the largest cholera outbreak (1,797 cases; attack rate 5.1 per 1,000) in the history of Dadaab refugee camp in Kenya occurred. Significant risk factors included living in a compound where open defecation, visible human and solid waste, and eating from a shared plate were common. Chlorine levels in water were below standard, and handwashing facilities were insufficient…..”

WHO: Cholera and Conflict


Crisis-driven cholera resurgence switches focus to oral vaccine

Oral rehydration was once the mainstay of treatment for cholera, but today’s cholera outbreaks fuelled by conflict and instability require a new approach. Sophie Cousins reports.

Bulletin of the World Health Organization 2018;96:446-447. doi:

Residents queue up to receive the oral cholera vaccine in he city of Nampula in Mozambique during the vaccination campaign in 2016.

WHO/L. Pezzoli

On a hot, humid afternoon at the world’s largest diarrhoeal disease hospital, dozens of patients are filing in, many being carried in the arms of loved ones, frail and barely alive.

Inside the Cholera Hospital – as it is commonly known – in Dhaka, at the icddr,b (formerly the International Centre for Diarrhoeal Disease Research, Bangladesh or ICDDR, B), hundreds of patients receive rehydration treatment.

Up to 1000 patients can be admitted each day at this time of the year, as the rains peak and temperatures soar. Outside the hospital, the ward has extended into circus-size tents in the car park. Most patients recover quickly and go home within 24 hours.

“We don’t say no to anyone and we don’t charge anyone,” says Dr Azharul Islam Khan, who is the chief physician and head of hospitals at the icddr,b.

The bacterium Vibrio cholerae has wreaked havoc for hundreds of years. Originating in the Ganges delta in India, the first recorded cholera epidemic started in 1817 and travelled along trade routes through Asia and to the shores of the Caspian and Mediterranean seas. Since then, regular outbreaks across the world have killed millions of people.

Cholera is an acute diarrhoeal infection caused by ingesting food or water contaminated with Vibrio cholerae. If left untreated, the infection can kill within hours. Each year between 1.3 to 4 million cases, and up to 143 000 deaths are reported to the World Health Organization (WHO). But the true burden of cholera is unknown.

“Reporting of cholera is not reliable. The number of cholera cases reported to us is considered to be the tip of the iceberg,” says Dr Dominique Legros, from WHO’s health emergencies programme.

There are many reasons for this, he says. For one, it’s difficult to confirm cases in large outbreaks where diagnostic capacity is limited. Second, the symptoms of less severe cholera are similar to those of other diarrhoeal diseases. Third, some countries may be reluctant to report cases of cholera for fear this will affect trade or tourism, Legros adds.

Bangladesh, an impoverished country of 162 million people, where cholera is endemic, has been at the forefront of the global fight against this ancient disease.

In the past 30 years, oral rehydration solution (ORS) – a mixture of salt, sugar and clean water – has saved an estimated 50 million lives worldwide, particularly those of children who are most vulnerable to diarrhoea-related dehydration.

The simple and inexpensive mixture was first formulated to treat cholera by researchers at the icddr,b in Dhaka and their colleagues at the Johns Hopkins Center for Medical Research and Training in Kolkata, India in the late 1960s.

“ORS is the mainstay in the prevention of dehydration,” Khan says. “Bangladesh has come a long way in terms of promoting ORS and raising awareness about how to treat cholera.”

ORS has helped Bangladesh to make huge strides in improving child health in recent decades. From 1988 to 1993, diarrhoea was the cause of almost one in five deaths among children under the age of five years. Between 2007 and 2011, only 2% of these deaths were related to diarrhoea, according to the Bangladesh Demographic and health survey 2011.

Today the United Nations Children’s Fund distributes around 500 million ORS sachets a year in 60 low and middle-income countries at a cost of around US$ 0.10 each.

Yet, while ORS has saved millions of lives, cholera shows no sign of waning, even in the region where it originated. Cholera still persists for very simple reasons: a lack of access to safe water, and poor sanitation and hygiene.

For Munirul Alam, senior scientist at the Infectious Diseases Division at the icddr,b, people living in conditions of overcrowding, poor hygiene and lack of access to safe water risk contracting cholera.

Around the world, as wars, humanitarian crises and natural disasters, such as flooding and droughts, uproot millions of people, destroy basic services and health-care facilities, cholera is surging.

Cholera broke out in conflict-torn Yemen almost two years ago. It has since claimed almost 2500 lives and infected about a million people in the country of 30 million. In Nigeria, three cholera outbreaks have already been declared this year in the country’s north-east, where millions have been displaced by conflict.

If ORS is so effective in preventing death, why are people still dying of cholera? “It’s the problem of access to care,” Legros says. “Cholera starts as acute diarrhoea and can quickly become extremely severe.”

“In emergency situations, where hospitals have been destroyed, are inaccessible or lack the basic resources, people with severe dehydration do not always receive intravenous rehydration treatment that they need.”

Severely dehydrated people need the rapid administration of intravenous fluids plus ORS during treatment, along with appropriate antibiotics to reduce the duration of diarrhoea and reduce the V. cholerae in their stool.

In Yemen, Dr Nahla Arishi, paediatric co-ordinator at Alsadaqah Hospital in Aden, a port city in the south of the country, is treating up to 300 cholera cases a day.

Last year the Yemeni paediatrician travelled to Dhaka’s icddr,b to participate in a week-long training on cholera and malnutrition case management and take back the skills and knowledge to her country.

Arishi, one of a team of 20 doctors and nurses from Yemen, learnt about the assessment of dehydration, food preparation, severe acute malnutrition and observed how the Cholera Hospital manages patients.

“They will be acting as good master trainers,” Khan says, adding that the icddr,b regularly deploys its experts to assist WHO and governments with the response to diarrhoeal diseases in emergencies.

While Arishi brought knowledge home with her, there are limits in applying these lessons. Battling cholera in Yemen is extremely challenging and the situation differs from that in Bangladesh.

Alsadaqah Hospital has ORS and intravenous fluids but the provision of these simple services is constantly disrupted – disruptions that can mean a matter of life and death, she says. “Electricity is on and off and is worse in summer, [it’s the] same with water [supplies].”

In emergencies such the one in Yemen, the oral cholera vaccine is playing an increasingly important role.

Currently there are three WHO pre-qualified oral cholera vaccines, two of which are used in areas experiencing outbreaks. They require two doses at least 14 days apart and can provide protection for up to five years.

In the last five years the use of these vaccines has increased exponentially, Legros says. The reason being that the vaccine is available, easy to use, well tolerated and addresses “a disease which people fear a lot.” “If you come with a vaccine, people will take it,” he says.

Rohingas in Cox Bazaar in south eastern Bangladesh receive the oral cholera vaccine in 2017.

WHO/W. Owens

In 2013, WHO established a stockpile of two million doses of oral vaccine financed by Gavi, the Vaccine Alliance, to respond to cholera outbreaks and to reduce the risk of outbreaks in humanitarian crises.

These settings include refugee camps, such as those for the Rohingyas in south-eastern Bangladesh, where two vaccination campaigns were completed between October and November 2017 and in May of this year.

The oral cholera vaccine has also been deployed in outbreaks in Haiti, Iraq and South Sudan, and recently in Malawi and Uganda.

“We’ve just started using the vaccine as a first stop for sustainable cholera control, followed up with water, sanitation and hygiene (WASH) interventions,” Legros says, referring to WASH measures that include improved water supply and sanitation, provision of safe drinking water and handwashing with soap.

But, Firdausi Qadri, a vaccine scientist and acting senior director of icddr,b’s Infectious Diseases Division, warns there aren’t enough vaccines stockpiled.

Last year an ambitious strategy to reduce cholera deaths by 90% by 2030 was launched by the Global Task Force on Cholera Control, a partnership of more than 30 health and development organizations including WHO, established in 2011.

According to Ending cholera: a global roadmap to 2030, which targets 47 countries, prevention and control can be achieved by taking a multisectoral approach and by combining the use of oral cholera vaccines with basic water, sanitation and hygiene services in addition to strengthening health-care systems and surveillance and reporting.

The roadmap also calls for a focus on cholera “hotspots,” places that are most affected by cholera – like the high risk areas in Bangladesh – that play an important role in the spread of cholera to other regions.

Bangladesh now has plans for a more systematic prevention and control of cholera, in line with the global strategy. To boost oral cholera vaccine supplies in the country, a local company is producing a vaccine, via technology transfer from India, and this could result in up to 50 million doses a year for the country, Qadri says.

But she recognizes that greater reliance on the vaccine will come at the expense of investing in water and sanitation hygiene services.

“Water, sanitation and hygiene interventions are what we need,” she says. “We have to change the whole environment and we have to educate people.”

Dr Khairul Islam, country director of WaterAid Bangladesh, agrees.

“No one would disagree that water, sanitation and hygiene interventions are ultimately the best way to prevent cholera and other water-borne gastrointestinal diseases,” he says.

From September of 2016 to March of 2018, officials in Yemen recorded 1,103,683 suspected cholera cases (attack rate, 3.69%) and 2,385 deaths (case-fatality rate, 0.22%)


Outbreak update – cholera in Yemen, 3 May 2018

3 May 2018 – The Ministry of Public Health and Population of Yemen has recorded 1942 suspected cases of cholera, and 2 associated deaths across the country during week 15 (9 – 15 April) in 2018. The cumulative total of suspected cholera cases stands at 1 090 280 and 2 275 associated deaths (case fatality rate 0.21%) since April 2017. Children under 5 years old represent 28.8% of the total suspected cases. So far 2 056 stool samples tested, and 1 115 have tested positive (36.5%) in addition to 42 793 rapid diagnosed tests performed.

The trend of new cases continue to decline. Out of 305 affected districts, 157 have not reported new cases for the past three consecutive weeks. Since the beginning of the year, the highest cumulative suspected cases have been reported in Al Hali (4 482), Maqbanah (1 809), Radman Al Awad (1 753) and Al Sabaeen(1 689),and AL Mighlaf (1 509) .

WHO leads the support to the Ministry along with Health and WASH partners to contain the outbreak through technical and logistical support. This includes strengthening disease surveillance; supporting operations in diarrhoeal treatment centres and oral rehydration corners; training the health workforce in case management; deploying rapid response teams; improving availability of safe water and sanitation.

Cholera is endemic in Yemen; the country has experienced a surge in cholera cases since April 2017 due to ongoing conflict, destroyed health, water and sanitation infrastructure and malnutrition, which has led the population to be more vulnerable to various epidemic-prone diseases, including cholera.

Diarrhea and Acute Respiratory Infection, Oral Cholera Vaccination Coverage, and Care-Seeking Behaviors of Rohingya Refugees — Cox’s Bazar, Bangladesh, October–November 2017


Summers A, Humphreys A, Leidman E, et al. Notes from the Field: Diarrhea and Acute Respiratory Infection, Oral Cholera Vaccination Coverage, and Care-Seeking Behaviors of Rohingya Refugees — Cox’s Bazar, Bangladesh, October–November 2017. MMWR Morb Mortal Wkly Rep 2018;67:533–535. DOI:

“……Violence in the Rakhine State of Myanmar, which began on August 25, 2017, prompted mass displacement of Rohingya to the bordering district of Cox’s Bazar, Bangladesh. Joining the nearly 213,000 Rohingya already in the region, an estimated 45,000 persons settled in two preexisting refugee camps, Nayapara and Kutupalong, and nearly 550,000 into new makeshift settlements (1). Mass violence and displacement, accompanied by malnutrition, overcrowding, poor hygiene, and lack of access to safe water and health care increase the vulnerability of children to infectious diseases, including pneumonia and diarrhea (2).…..”


A massive cholera vaccination campaign begins to protect nearly one million Rohingyas and their host communities living in and around the refugee camps in Bangladesh


One million Rohingya refugees, host communities being vaccinated against cholera

Cox’s Bazar, 6 May 2018: A massive cholera vaccination campaign began today to protect nearly one million Rohingyas and their host communities living in and around the refugee camps in Bangladesh, to prevent any potential outbreak during the ongoing monsoon season.

This is a second cholera vaccination campaign being held for the Rohingyas and their host communities. Earlier 900,000 doses of oral cholera vaccine were administered to the vulnerable population in two phases in October – November last year.

“Considering the water and sanitation conditions in the overcrowded camps and the increased risk of disease outbreaks in the monsoon season, the health sector is taking all possible measures to prevent cholera and other water and vector borne diseases,” says Dr. Bardan Jung Rana, WHO Representative to Bangladesh.

As many as 245 mobile vaccination teams have been deployed to vaccinate all people over the age of one year in refugee camps and host communities in Ukhiya and Teknaf sub-districts during nearly week-long campaign led by the Ministry of Health and Family Welfare, with support of World Health Organization, UNICEF and icddr,b and other partners.

“We have managed to prevent the cholera outbreak since the first campaign in October last year, but flood water, heavy storms and landslides in the monsoon season could damage water and sanitation facilities in the camps, increasing the risk again of an outbreak of this dangerous disease. We have to take all initiatives to address the risk, including preventive measures through vaccination,” says Edouard Beigbeder, UNICEF Representative in Bangladesh.

The oral cholera vaccines have been made available through the Inter-Agency Coordinating Group with members from WHO, UNICEF, Médecins sans Frontières and International Federation of the Red Cross. The vaccines and supplies are financed by Gavi, the vaccine alliance.

“This vaccination campaign is a part of the ongoing efforts of the government and the health sector partners to protect nearly a million people, including at least 135,000 Bangladeshis, who have been affected by the influx since last year,” says Professor Dr. Abul Kalam Azad, Director General of Health Services (DGHS), Ministry of Health and Family Welfare, Government of Bangladesh.

In addition to vaccination, consistent efforts are being made to improve access to clean water and sanitation and promote hygiene. UNICEF has been scaling up interventions and communication on safe practices.

The World Health Organization has raised an early warning, alert and response emergency surveillance system, is monitoring water quality and working with the Department of Public Health Engineering to enhance local laboratory capacity.

Both WHO and UNICEF have prepositioned life-saving supplies to ensure rapid response to any outbreak.

The WHO-led Health Sector is supporting setting up of diarrhea treatment centres, including five supported by UNICEF and managed by icddr,b.

Editorial Note:

The Maternal Neonatal and Adolescent Health (MNC&AH) of Director General of Health Services (DGHS) is leading the oral cholera vaccination campaign through district and upazila level health managers and administration as well as DGHS Coordination Cell in Cox’s Bazar, Armed Forces, Refugee Relief and Repatriation Commission (RRRC), development partners, including UN agencies, and national and international non-government organizations.

Two million people in five African countries to be vaccinated against cholera


A spate of cholera outbreaks across Africa has prompted the largest cholera vaccination drive in history, with more than two million people across the continent set to receive oral cholera vaccine (OCV).


The vaccines, funded by Gavi, the Vaccine Alliance, were sourced from the global stockpile and are being used to carry out five major campaigns in Zambia, Uganda, Malawi, South Sudan and Nigeria. The campaigns, which will be completed by mid-June, are being implemented by the respective Ministries of Health supported by the World Health Organization (WHO) and partners of the Global Task Force on Cholera Control (GTFCC), and mostly in reaction to recent cholera outbreaks.


In the 15 years between 1997 and 2012 just 1.5 million doses of cholera vaccines were used worldwide. In 2017 alone almost 11 million were used, from Sierra Leone to Somalia to Bangladesh. In the first four months of 2018 over 15 million doses have already been approved for use worldwide.


“This is an unprecedented response to a spike in cholera outbreaks across Africa,” said Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance. “We have worked hard to ensure there is now enough vaccine supply to keep the global stockpile topped up and ready for most eventualities. However with more and more people now succumbing to this terrible, preventable disease, the need for improved water and sanitation – the only long-term, sustainable solution to cholera outbreaks – has never been clearer.”


Through its Regional Office for Africa, WHO regularly provides technical and operational support to countries often affected by cholera in Africa. In particular, since the beginning of 2018 WHO has led on providing technical expertise and guidance, working closely with Ministries of Health in the five countries to plan and implement the campaigns with different partners. This is part of a global push to reduce cholera deaths by 90 percent by 2030.


“Oral cholera vaccines are a key weapon in our fight against cholera,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “But there are many other things we need to do to keep people safe. WHO and our partners are saving lives every day by improving access to clean water and sanitation, establishing treatment centres, delivering supplies, distributing public health guidance, training health workers, and working with communities on prevention.”


The burden of cholera remains high in many African countries. As of 7 May many countries are facing cholera outbreaks, with at least 12 areas or countries reporting active cholera transmission in sub-Saharan Africa. Recent developments in the use of OCVs show that the strong mobilisation of countries and partners can effectively tackle the disease when tools for prevention and control are readily available.


“Every rainy season, cholera springs up and brings devastation to communities across Africa,” said Dr Matshidiso Moeti, WHO’s Regional Director for Africa. “With this historic cholera vaccination drive, countries in the region are demonstrating their commitment to stopping cholera from claiming more lives. We need to build on this momentum through a multisectoral approach and ensure that everyone has access to clean water and sanitation, no matter where they are located.”


The five African campaigns are:


  • Nigeria
    1.2 million doses will protect around 600,000 people to contain an emerging cholera outbreak in Bauchi state, where more than 1700 cases have been reported.
  • MalawiOne million doses of cholera vaccine will protect over 500,000 people in Lilongwe to combat an outbreak which has infected more than 900 people across the country.
  • Uganda360,000 doses of cholera vaccine have been shipped to Uganda to protect 360,000 people in Hoima District, Western Uganda, after an outbreak in Kyangwali refugee camp hospitalized more than 900 people. The country is also now engaging in long-term cholera control planning to vaccinate over 1.7 million people in the coming months.
  • Zambia667,100 doses of cholera vaccine are being delivered as part of the second round of vaccination to the Lusaka slums after a major outbreak infected over 5700 people, killing more than 100. Zambia is also engaging on long term cholera control and planning vaccination in additional hotspots.
  • South Sudan

113,800 doses have been shipped as a preventative measure ahead of the war-torn country’s rainy season. These extra doses will complement doses remaining from previous campaigns to target Panyijiar. Over 2.6 million doses of OCV have been administered in South Sudan since 2014.


Oral Cholera Vaccine is recommended to be given in two doses. The first gives protection for six months, the second for three to five years. All five campaigns should have completed their second round of vaccinations by mid-June.


A resolution on cholera will be proposed by Zambia and Haiti at this month’s World Health Assembly, calling for renewed political will and an integrated approached to eliminate cholera, including investment in clean water, sanitation and hygiene (WASH).


The global cholera vaccine stockpile is managed by the Global Task Force on Cholera Control (GTFCC), which decides on OCV use in non-emergency settings, and the International Coordinating Group (ICG), which decides on outbreak response and features representatives from WHO, UNICEF, the International Federation of the Red Cross and Red Crescent Societies (IFRC) and Medecins Sans Frontières (MSF). The stockpile is funded in full by Gavi, the Vaccine Alliance, which is a GTFCC partner and has an observer status on the ICG.


Yemen: From Sept 28, 2016, to March 12, 2018, 1 103 683 suspected cholera cases (attack rate 3·69%) and 2385 deaths (case fatality risk 0·22%) were reported countrywide.


“….Our analysis suggests that the small first cholera epidemic wave seeded cholera across Yemen during the dry season. When the rains returned in April, 2017, they triggered widespread cholera transmission that led to the large second wave. These results suggest that cholera could resurge during the ongoing 2018 rainy season if transmission remains active. Therefore, health authorities and partners should immediately enhance current control efforts to mitigate the risk of a new cholera epidemic wave in Yemen.…”


Malawi: Cholera cases pass 500 with 8 dead




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