WHO

CDC

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: http://dx.doi.org/10.15585/mmwr.mm6718a6.

“……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).…..”

WHO

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.

WHO

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.

Lancet

“….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.…”

Reuters

WHO

uba, South Sudan, 07 February 2018 – South Sudan declared the end of its longest and largest cholera outbreak on Wednesday (February 07), with no new cases of cholera reported in over seven weeks.

The fight against cholera in South Sudan has involved a range of partners working together to enhance surveillance, deploy rapid response teams to investigate and respond to cases, provide clean water, promote good hygiene practices and treat cholera patients.

To enhance outbreak response efforts, the government worked with the European Union Humanitarian Aid (ECHO), GAVI, the Vaccine Alliance, the United States Agency for International Development (USAID) and the World Health Organization (WHO), securing 2.2 million doses of the Oral Cholera Vaccine (OCV) from the Gavi-funded global stockpile.

In 2017 more than 885,000 people at higher risk of cholera were immunized in the first round and nearly 500,000 people also received a second round of the vaccine. Due to security challenges, not everyone was able to receive the recommended two doses, which would significantly decrease their risk of being affected by cholera.

“Cholera is a virulent disease which spreads when hygiene and sanitation are inadequate,” said Evans Liyosi, WHO Acting Representative to South Sudan. “I congratulate South Sudan for resolving to tackle cholera with determination. But cholera is endemic to South Sudan and many risk factors remain. It is important to maintain the ability to detect and respond to new cases.”

The outbreak was declared on 18 June 2016 and spread to many parts of the country, including the capital Juba. By the time the last confirmed cholera case was discharged on 18 December 2017, over 20,000 suspected cholera cases and 436 deaths were reported.

The country is dealing with several complex health emergencies with 5.1 million people in need of health assistance. Armed conflict has forced almost 4 million people to flee their homes.

Nearly 5 million people, more than 40% of the population, are severely food insecure. These challenges place a huge burden on the country’s health system, while the sanitation infrastructure needs further strengthening.

“The achievements of South Sudan’s cholera programme are impressive,” said Mr Liyosi. “But in a few months a new rainy season will begin, increasing the risk of cholera. Together we must stay on the alert for warning signs that could signal another outbreak.”

WHO

The Government of Zambia has launched a campaign on Wednesday (January 10) to vaccinate residents of Lusaka against cholera with support from the World Health Organization and partners.

Two million doses of the oral cholera vaccine from the Gavi-funded global stockpile were delivered to the southern African country in January, enough to immunize 1 million people.

According to Health Minister Dr Chitalu Chilufya, the campaign will bring the life-saving oral cholera vaccine to the people who need it most. He also highlighted the role that communities can play in preventing the spread of the disease. “Communities should not ignore basic preventative measures because the key drivers of this epidemic include consumption of contaminated water and food, poor waste management, and poor personal hygiene practices which have to change,” said Dr Chilufya.

Cholera is an acute diarrhoeal disease that can kill within hours if left untreated. Since the start of the current outbreak on 4 October 2017, the Ministry of Health reports that there have been a total of 2,672 cases, with Lusaka alone accounting for 2,558 cases. There have been 63 deaths countrywide, 58 of which in Lusaka.

WHO is working with the Zambia National Public Health Institute (ZNPHI) to address the underlying causes of the cholera outbreak: clean water provision, sanitation and health education on personal hygiene. WHO is also helping authorities to track down cases, treat cholera patients and provide community health education.

Selected vaccination sites in central areas of Lusaka will be targeted under the campaign. WHO has provided training to medical personnel in how to administer the vaccine, as well as on other preventive measures and cholera treatment.

“Zambia is experiencing one of the worst outbreaks of cholera in years,” said Dr. Nathan Bakyaita, WHO Representative to Zambia. “With this campaign, we can stop cholera in its tracks and prevent an even more devastating epidemic.”

While sporadic cases of cholera are regular occurrences in Zambia during the five-month rainy season, the number of cases this year has exceeded the average annual caseload.

WHO recommends that vaccination against cholera be considered in emergencies and other high-risk scenarios where there are increased threats of outbreaks, when combined with standard prevention and control measures for the disease. These measures include readiness to provide adequate testing and treatment, steps to ensure access to safe water and sanitation, and community mobilization to engage the public in preventing infection.

Planning is underway to vaccinate a further 1 million people living in known cholera hotspots across the country later this year.

WHO

Cholera – Zambia

On 6 October 2017, the Minister of Health declared an outbreak of cholera in the Zambian capital, Lusaka. From 28 September through 7 December 2017, 547 cases including 15 deaths (case fatality rate = 1.8%), have been reported since the beginning of the outbreak. The initial outbreak period was from 28 September through 20 October. From 21 October through 4 November 2017 there were less than five cases reported each week. However, from 5 November 2017 an increase in the number of cases was observed with a total of 136 cases reported in the week beginning 26 November.

Figure 1: Number of cholera cases in Zambia reported by date of illness onset from 28 September to 2 December 2017

The cholera outbreak initially started in the Chipata sub-district and spread to Kanyama sub-district around 9 October 2017. The outbreak has spread from the peri-urban townships on the Western side of Lusaka City to the Eastern Side with a new case reported in Chelstone sub-district. As of 7 December, the affected sub-districts include Chipata, Kanyama, Chawama, Matero, Chilenje and Chelston. Sixty-two cases are currently receiving treatment in Cholera Treatment Centres in Chipata, Kanyama, Matero and Bauleni. One third of the cases are children under five years old and two thirds are persons five years and older.

A total of 282 Rapid Diagnostic Tests were performed, of which 230 were positive. Of 310 culture tests, 53 were positive for Vibrio cholerae O1 Ogawa (48 from Chipata, four from Kanyama and one from Bauleni). Water quality monitoring is ongoing in all sub-districts, with intensified activity in Kanyama, Matero and Chipata. The results so far show that nearly 42% of tested water sources are contaminated with either Faecal Coliforms or Escherichia coli.

Public health response

The following public health measures are currently being implemented:

• The Ministry of Health is collaborating with WHO and other partners to control the outbreak.
• Five Cholera Treatment Centres have been established in Chawama, Chipata, Kanyama, Matero and Bauleni sub-districts to manage cases. So far, 441 cases were successfully treated and discharged.
• Cholera Outbreak Guidelines and standard operating procedures have been updated and shared with health workers.
• The facilities in Lusaka District have continued with active surveillance, health education, chlorine distribution, contact tracing and environmental health monitoring.
• The local authorities in collaboration with the Ministry of Health have embarked on closing contaminated water points and has implemented Water Sanitation and Hygiene (WASH) interventions to improve water supplies in affected areas. This includes provision of household chlorine, disinfection of pit latrines, erection of water tanks, installation of water purifiers and intensification of water quality monitoring.
• The Lusaka City Council has intensified collection of garbage and emptying of septic tanks in Kanyama and Chipata as priority areas.

WHO risk assessment

The current outbreak is occurring in Zambia’s largest city, Lusaka. The main affected sub-districts, Chipata and Kanyama, are densely populated and have an inadequate water and sanitation infrastructure, which may favour the spread of the disease. The sources of infection transmission in this outbreak have been associated with contaminated water supplies, contaminated food, inadequate sanitation and poor hygiene practices.

The coming of the rainy season, coupled with inadequate water supply and sanitation increases the risk of outbreaks in Lusaka and other parts of the country. Adequate supplies for cholera response should be obtained as part of preparedness activities.

Zambia hosts about 60 000 refugees (as of September 2017) from neighbouring countries. A large proportion of refugees are from the Democratic Republic of the Congo (DRC) and are mostly residing in Nchelenge refugee camp located more than 1000 km distant from Lusaka. The influx of refugees has led to overcrowded settlements with high needs for shelter, healthcare and WASH facilities. Most refugees are in poor health condition, especially children; therefore, risk of disease outbreaks is high. Sanitation is a challenge at hosting sites. Given the security situation in DRC, further influx of refugees is expected.

WHO advice

WHO recommends proper and timely case management in Cholera Treatment Centres. Improving access to potable water and sanitation infrastructure, and improved hygiene and food safety practices in affected communities, are the most effective means of controlling cholera. Use of oral cholera vaccine may also be used for outbreak control. Key public health communication messages should be provided.

WHO advises against any restriction to travel to and trade with Zambia based on the information available on the current outbreak.

For more information on cholera, please see the link below:

• Fact sheet on cholera

WHO

Cholera – Kenya

From 1 January though 29 November 2017, a total of 3967 laboratory-confirmed and probable cases including 76 deaths (case fatality rate = 1.9%) were reported by the Ministry of Health to WHO. Of the cases reported, 596 were laboratory confirmed.

Figure 1: Number of confirmed and probable cases in Kenya reported by week of illness onset from 1 January through 25 November 2017¹

¹Date of illness onset is missing for 92 cases.

From 1 January 2017 through 29 November, 20 of 47 counties (43%) in Kenya have reported cases. As of 29 November, seven counties continue to have active cholera outbreaks (Embu, Garissa, Kirinyaga, Mombasa, Nairobi, Turkana, and Wajir).

The epidemiology of cholera for Kenya in 2017 is characterized by continuous transmission in affected communities coupled with outbreaks in camp settings and institutions or during mass gathering events. Continuous transmission in the community accounts for around 70% of the total cases with the majority of cases coming from the capital county, Nairobi. Transmission in camp settings occurred mainly within Garissa and Turkana counties, accounting for around 23% of the total reported cases. Both counties host big refugee camps, namely Dadaab and Kakuma refugee camps. Refugees in these camps come from countries currently experiencing complex emergencies and large cholera outbreaks. Seven percent of cases occurred in institutions and mass gathering events, where a number of people get infected from a point source.

The country experiences cholera outbreaks every year; however, large cyclical epidemics occur approximately every five to seven years and last for two to three years.

Public health response

The country has activated the national task force to coordinate the outbreak response activities. Since January 2017, WHO and other partners have been providing technical support to the country to control of the outbreak. Following the development of the national response plan, WHO and other partners supported the country to scale-up the outbreak response activities such as surveillance, case management, and social mobilization. This was also coupled with the improvement of food hygiene standards and promotion of safe food handling, besides scaling-up Water, Sanitation, and Hygiene (WASH) related activities. This resulted in a decline in the number of cholera cases.

WHO risk assessment

Despite the decline in the number of cases reported, the outbreak appears to be clustered around two major types of settings. First, the refugee camps particularly Kakuma and Dadaab, and second in the populous Nairobi capital county. Both settings are concerning, considering the overcrowded conditions and limited access to care in the first setting, and the high population density in the second setting. This could enable the spread of the outbreak to other districts. Also, previous outbreaks have shown that cases increase during the rainy season, which has started recently.

In addition, various physical, social, political, and environmental factors increase the vulnerability and the susceptibility of the country’s population to the cholera outbreaks. These include regional drought, conflict, and insecurity in the Horn of Africa, and the increased movement within and to the country by people fleeing conflicts in Somalia and South Sudan.

Overall, the risk of the current outbreak is assessed as high at the national level and low at the regional and global levels.

WHO advice

WHO recommends proper and timely case management in cholera treatment centres. The affected communities should have improved access to water, effective sanitation, proper waste management, and enhanced hygiene and food safety practices. Key public health communication messages should be provided. WHO encourages travellers to the affected area to take proper hygiene precautions to prevent potential exposure.

WHO does not recommend any restriction on travel and trade to Kenya based on the information available on the current outbreak.

For more information on cholera, please see the link below:

• WHO fact sheet on cholera