In the rush to tackle emerging public health concerns like mpox and Covid-19, are diseases like cholera being overlooked? Rapid urbanisation, climate change, and conflicts are putting pressure on healthcare systems, say international agencies, calling for renewed attention on neglected diseases like cholera through efforts, including vaccination, to fortify public health.
Cholera is an acute diarrhoeal disease that can kill within hours if left untreated, says the World Health Organization.
Earlier this year, the International Coordinating Group (ICG) on Vaccine Provision had said there was “an unprecedented multi-year upsurge in cholera cases worldwide” and called for immediate remedial action. The ICG, which manages the global cholera vaccine stockpile, had red-flagged the severe demand-supply gap.
Late August, Hyderabad’s Bharat Biotech launched an oral cholera vaccine (OCV), Hillchol — licensed from Hilleman Laboratories — putting the focus back on cholera.
Deadly outbreaks
Cholera annually affects 13-14 lakh people globally, and causes upto 1.43 lakh deaths. India is among the affected regions as cholera outbreaks, both endemic and epidemic, persist in developing countries across Africa, Asia, and the Americas.
Avash Pani, consultant paediatrician at Hyderabad’s Apollo Cradle and Children’s Hospital, points out that cholera symptoms — including severe watery diarrhoea, vomiting, and dehydration — can turn life-threatening if not treated quickly. The treatment involves rehydration (orally or intravenously), and antibiotics (if severe).
“There is a shortage of oral cholera vaccines globally. This poses a challenge to largescale immunisation efforts,’’ he says, adding that new vaccines like Hillchol would be a welcome addition. Moreover, there is a need to step up other prevention efforts, including access to improved water, sanitation, and hygiene (WASH), Pani says.
Hillchol’s rollout comes amid a global shortage of 40 million OCV doses annually, even as demand exceeds 100 million doses. Bharat Biotech can look to bridge this gap, says its Executive Chairman Krishna Ella.
Vaccine basket
According to WHO, there are three pre-qualified OCVs — Dukoral (from Valneva Sweden AB), Shanchol (Sanofi Healthcare) and Euvichol-Plus (EuBiologics). All three require two doses, given to anyone over a year old. Dukoral is largely taken by travellers. Hillchol, too, has a similar regimen.
OCV’s inclusion in the public vaccination programme can help combat the disease, says Ella.
As Dr Jan Holmgren, the Swedish physician and microbiologist, regarded as the ‘Father of OCVs’, explains, “Cholera is a serious infection that can have devastating consequences for many communities. Unlike existing cholera vaccines, which contain more than one strain, Hillchol utilises a single, genetically engineered, inactivated ‘Hikojima’ strain delivered orally.”
This vaccine is cheaper to produce and can expand access, he says. It can also help achieve the WHO’s targeted end of cholera by 2030, he adds, urging India to introduce Hillchol in its public health vaccination programme.
Doctors remain divided over its inclusion in national immunisation as the disease is limited to specific regions. However, K Hari Prasad, Group Chairman and Non-Executive Director of hospital chain Quality Care India, observes, “Although the incidence has come down, prevention is always better than cure.”
Tip of the iceberg
In 2022, cholera outbreaks were reported in over 29 countries, with Africa and the Eastern Mediterranean region among the worst-affected, the WHO said. The number of cases had more than doubled from the previous year. In 2023, a total of 5,35,321 cases and 4,007 deaths were reported from 45 countries.
This could just be the tip of the iceberg as many cases are not recorded due to limitations in surveillance systems and the fear of impact on trade and tourism, the WHO observed.
In India, cholera has been a concern in Maharashtra, Odisha and Madhya Pradesh. But with rains and floods becoming a frequent occurrence, more regions run the risk of an outbreak, making it imperative to equip health authorities with all the tools available to stop the spread.