Millions at risk of cholera due to lack of clean water, soap and toilets and lack of cholera vaccine

Urgent action is needed to stop an unprecedented multi-year rise in cholera cases worldwide, according to the International Vaccine Coordination Group (ICG). Actions include investing in access to safe water, sanitation and hygiene, testing and rapid outbreak detection, improving quality and access to health care, and fast-tracking additional production of affordable doses of oral cholera vaccine (OCV) to better prevent cases.

ICG manages the global supply of cholera vaccines. The group includes the International Federation of Red Cross and Red Crescent Societies, Doctors Without Borders, UNICEF and WHO. Gavi, the Vaccine Alliance, is funding the vaccine stockpile and the delivery of OCV. ICG members call on governments, donors, vaccine manufacturers, partners and communities to join in urgent efforts to halt and reverse the rise of cholera.

Cholera has been on the rise globally since 2021, with 473,000 cases reported to WHO in 2022, more than double those reported in 2021. Preliminary data for 2023 reveal a further increase, with more than 700,000 cases reported. Several outbreaks have high mortality rates, exceeding the 1% threshold used as an indicator for early and appropriate treatment of cholera patients. These trends are tragic given that cholera is a preventable and treatable disease and that cases have been on the decline in previous years.

Cholera is an acute intestinal infection that spreads through food and water contaminated with faeces containing the bacteria Vibrio cholerae. The increase in cholera is fueled by persistent deficiencies in access to safe water and sanitation. While efforts are being made in some places to fill these gaps, in many others the gaps are growing, driven by factors related to climate, economic insecurity, conflict and population displacement. Safely managed water and sanitation are prerequisites for stopping cholera transmission.

Currently the worst affected countries include the Democratic Republic of the Congo, Ethiopia, Haiti, Somalia, Sudan, Syria, Zambia and Zimbabwe.

Now more than ever, countries must adopt a multisectoral response to fight cholera. ICG members call on currently and potentially affected countries to take immediate steps to ensure their populations have access to clean water, hygiene and sanitation services, and information critical to preventing the spread of cholera. The establishment of these services requires political will and investments at the state level. This includes building capacity for early detection and response, improved disease detection, rapid access to treatment and care, and close collaboration with communities, including risk communication and community engagement.

The severe gap in the number of vaccine doses available, compared to the level of current need, is putting unprecedented pressure on the global vaccine supply. Between 2021 and 2023, more outbreak response doses were requested than in the entire previous decade.

In October 2022, ongoing vaccine shortages forced the ICG to recommend a single dose of the vaccine, as opposed to the previous, long-term, two-dose regimen. Last year, approximately 36 million doses were produced, while the 14 affected countries registered a need for 72 million doses for the reactive single-dose strategy. These requirements underestimate the real need. Preventive vaccination campaigns had to be delayed to save doses for emergency efforts to control the outbreak, creating a vicious cycle. The change in strategy allowed available vaccines to protect more people and respond to more cholera outbreaks amid ongoing supply shortages, but a return to a two-dose regimen and continued preventive vaccination would provide longer protection.

Global production capacity is projected to be 37-50 million doses in 2024, but is likely to remain insufficient to meet the needs of the millions of people directly affected by cholera. Only one manufacturer, EuBiologicks, currently produces the vaccine; while the company is doing everything in its power to increase the effect, more doses are needed. No new manufacturers are currently expected to join the market before 2025; they must be fast tracked. The same urgency and innovation we saw for COVID-19 must be applied to cholera.

Additional manufacturers planning to enter the market should accelerate their efforts and make doses available at affordable prices.

We appeal to vaccine manufacturers, governments, donors and partners to prioritize an urgent increase in vaccine production and to make all necessary efforts to prevent and control cholera.