Safe water, sanitation and hygiene are crucial in protecting people from cholera.
Improving water and sanitation services and general hygiene have proven effective
in controlling and eliminating cholera in many countries. In the 47 low- and middle-income
countries affected by cholera, only 79% and 44% of the population uses basic water
and sanitation services respectively, compared to 94% and 79% in low- and middle-income
countries without cholera.
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The oral cholera vaccine is perceived as an interim solution that can be deployed
in advance of, or together with, investments in water sanitation and hygiene.
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As oral cholera vaccine is currently being considered as part of Gavi, the Vaccine
Alliance’s portfolio, the vaccine’s use in endemic settings could become even more
common.
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However, a more widespread use of oral cholera vaccine should not come at the expense
of investing in and sustaining water sanitation and hygiene services, particularly
in cholera hotspot areas, such as urban slums and remote rural villages that pose
logistical and technological challenges.
Oral cholera vaccine comes at a cost. In Zambia each dose of vaccine costs 2.31 United
States dollars (US$) and the benefits are limited to Vibrio cholerae, with a protective
effect of five years at most. Efforts to improve water sanitation and hygiene, on
the other hand, have a relatively high return: US$ 4.30 for every dollar invested
in water and sanitation,
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in addition to prevention of most waterborne diseases and time saved from not having
to fetch water.
Furthermore, several water sanitation and hygiene interventions can be implemented
quickly and cheaply, such as point-of-use water treatment and safe storage, community
action to end open defecation, provision of soap and promotion of handwashing. The
United Nations Children’s Fund (UNICEF) and World Health Organization (WHO) Joint
Monitoring Programme reports that many low-income countries, such as Cambodia and
Ethiopia, have made rapid progress on, for example, eliminating open defecation, which
has been shown to significantly reduce diarrhoeal diseases.
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The reasonable alternative would be to pursue both oral cholera vaccine and water
sanitation and hygiene efforts in parallel as done in, for example, Zanzibar, the
United Republic of Tanzania and in Zambia.
Zanzibar, the United Republic of Tanzania, has worked with health sector and water,
hygiene and sanitation partners to develop a 10-year cholera elimination plan,
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aligned to the new global roadmap. The plan specifically targets five hotspots where
infection rates ranged between 80% and 95%. Cholera epidemics in these hotspots are
closely linked to poor water sanitation and hygiene access. The plan involves high-level
political leadership, ensuring engagement of relevant ministries and encouraging donors
to support and invest in the plan.
In Zambia, the cholera outbreak which started in 2017 in Lusaka, now totals over 5000
cases and has resulted in nearly 100 deaths.
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Intensive door-to-door hygiene promotion, hygiene kits distribution and enhanced water-quality
testing and monitoring in the most affected sub-districts of Lusaka is helping to
curb the outbreak in these areas. However, the elimination of cholera in Zambia will
require investing in both short- and long-term water sanitation and hygiene services
in all hotspots.
The Global Task Force on Cholera Control considers water, sanitation and hygiene investments
as the foundation to meeting the goal of reducing cholera deaths by 90% by 2030.
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We argue that three main actions need to be taken to ensure that such investments
are prioritized as part of the renewed efforts to end cholera.
First, when countries request oral cholera vaccine, they should engage in water sanitation
and hygiene efforts. These efforts should include a systematic analysis of water sanitation
and hygiene needs, priorities and potential financing mechanisms. In the recent roll-out
of oral cholera vaccination in Malawi, although water and sanitation conditions were
taken into account in prioritizing target populations, concrete actions on water and
sanitation were not mentioned.
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A joint vaccination and hygiene campaign along with securing political and financial
commitments on water and sanitation would advance prevention and control of cholera
in Malawi.
Second, efforts should be made to ensure that initiatives to strengthen health systems
and provide quality care devote sufficient resources for providing and sustaining
water and sanitation services, especially in cholera treatment centres. The response
that WHO, UNICEF and partners are developing to address the United Nations Secretary
General’s call for action on water, sanitation and hygiene in health-care facilities
provides new momentum to address these inadequacies.
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Third, donors and partners must align behind national multisectoral cholera control
plans, not simply invest in stand-alone interventions. This shift will require understanding
the political dynamics and support for common metrics and accountability.
A shared vision and unanimous agreement among Member States, partners and donors to
prioritize broader social and environmental determinants of health, including water,
sanitation and hygiene, is needed to end cholera. A proposed World Health Assembly
resolution seeks to promote this consensus, ensure effective multisectoral collaborations
and address cholera in tandem with other diarrhoeal diseases.