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Information on the infectious disease

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Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. Cholera remains a global threat to public health and an indicator of inequity and lack of social development.

Symptoms

Cholera is an extremely virulent disease that can cause severe acute watery diarrhoea. It takes between 12 hours and 5 days for a person to show symptoms after ingesting contaminated food or water (2). Cholera affects both children and adults and can kill within hours if untreated.

Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people.

Among people who develop symptoms, the majority have mild or moderate symptoms, while a minority develop acute watery diarrhoea with severe dehydration. This can lead to death if left untreated.

History

During the 19th century, cholera spread across the world from its original reservoir in the Ganges delta in India. Six subsequent pandemics killed millions of people across all continents. The current (seventh) pandemic started in South Asia in 1961, reached Africa in 1971 and the Americas in 1991. Cholera is now endemic in many countries.

Vibrio cholerae strains

There are many serogroups of V. cholerae, but only two - O1 and O139 - cause outbreaks. V. cholerae O1 has caused all recent outbreaks. V. cholerae O139 - first identified in Bangladesh in 1992 - caused outbreaks in the past, but recently has only been identified in sporadic cases. It has never been identified outside Asia. There is no difference in the illness caused by the two serogroups.

Epidemiology, risk factors, and disease burden

Cholera can be endemic or epidemic. A cholera-endemic area is an area where confirmed cholera cases were detected during the last 3 years with evidence of local transmission (meaning the cases are not imported from elsewhere). A cholera outbreak/epidemic can occur in both endemic countries and in countries where cholera does not regularly occur.

In cholera endemic countries an outbreak can be seasonal or sporadic and represents a greater than expected number of cases. In a country where cholera does not regularly occur, an outbreak is defined by the occurrence of at least 1 confirmed case of cholera with evidence of local transmission in an area where there is not usually cholera.

Cholera transmission is closely linked to inadequate access to clean water and sanitation facilities. Typical at-risk areas include peri-urban slums, and camps for internally displaced persons or refugees, where minimum requirements of clean water and sanitation are not been met.

The consequences of a humanitarian crisis - such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps - can increase the risk of cholera transmission, should the bacteria be present or introduced. Uninfected dead bodies have never been reported as the source of epidemics.

The number of cholera cases reported to WHO has continued to be high over the last few years. During 2020 323 369 cases, 857 deaths were notified from 24 countries ³. The discrepancy between these figures and the estimated burden of the disease is due many cases not being recorded due to limitations in surveillance systems and fear of impact on trade and tourism.

Prevention and control

A multifaceted approach is key to control cholera, and to reduce deaths. A combination of surveillance, water, sanitation and hygiene, social mobilisation, treatment, and oral cholera vaccines are used.

Surveillance

Cholera surveillance should be part of an integrated disease surveillance system that includes feedback at the local level and information-sharing at the global level.

Cholera cases are detected based on clinical suspicion in patients who present with severe acute watery diarrhoea. The suspicion is then confirmed by identifying V. cholerae in stool samples from affected patients. Detection can be facilitated using rapid diagnostic tests (RDTs), where one or more positive samples triggers a cholera alert. The samples are sent to a laboratory for confirmation by culture or PCR. Local capacity to detect (diagnose) and monitor (collect, compile, and analyse data) cholera occurrence, is central to an effective surveillance system and to planning control measures.

Countries affected by cholera are encouraged to strengthen disease surveillance and national preparedness to rapidly detect and respond to outbreaks. Under the International Health Regulations, notification of all cases of cholera is no longer mandatory. However, public health events involving cholera must always be assessed against the criteria provided in the regulations to determine whether there is a need for official notification.

Water and sanitation interventions

The long-term solution for cholera control lies in economic development and universal access to safe drinking water and adequate sanitation. Actions targeting environmental conditions include the implementation of adapted long-term sustainable WASH solutions to ensure use of safe water, basic sanitation and good hygiene practices in cholera hotspots. In addition to cholera, such interventions prevent a wide range of other water-borne illnesses, as well as contributing to achieving goals related to poverty, malnutrition, and education. The WASH solutions for cholera are aligned with those of the Sustainable Development Goals (SDG 6).

More information on IHR Annex 2

Treatment

Cholera is an easily treatable disease. The majority of people can be treated successfully through prompt administration of oral rehydration solution (ORS). The WHO/UNICEF ORS standard sachet is dissolved in 1 litre (L) of clean water. Adult patients may require up to 6 L of ORS to treat moderate dehydration on the first day.

Severely dehydrated patients are at risk of shock and require the rapid administration of intravenous fluids. These patients are also given appropriate antibiotics to diminish the duration of diarrhoea, reduce the volume of rehydration fluids needed, and shorten the amount and duration of V. cholerae excretion in their stool.

Mass administration of antibiotics is not recommended, as it has no proven effect on the spread of cholera may contribute to antimicrobial resistance.

Rapid access to treatment is essential during a cholera outbreak. Oral rehydration should be available in communities, in addition to larger treatment centres that can provide intravenous fluids and 24 hour care. With early and proper treatment, the case fatality rate should remain below 1%.

Zinc is an important adjunctive therapy for children under 5, which also reduces the duration of diarrhoea and may prevent future episodes of other causes of acute watery diarrhoea.

Breastfeeding should also be promoted.

Community Engagement

Community Engagement means that people and communities are part of the process of developing and implementing programmes. Local culture practices and beliefs are central to promoting actions such as the adoption of protective hygiene measures such as handwashing with soap, safe preparation and storage of food and safe disposal of the faeces of children.funeral practices for individuals who die from cholera to prevent infection among attendees.

Community engagement continues throughout outbreak response with increased communication regarding potential risks, symptoms of cholera, precautions to take to avoid cholera, when and where to report cases and to seek immediate treatment when symptoms appear. The communities should be part of developing programmes to address needs including where and when to seek treatment.

Oral cholera vaccines

Currently there are three WHO pre-qualified oral cholera vaccines (OCV): Dukoral®, Shanchol™, and Euvichol-Plus®. All three vaccines require two doses for full protection.

Dukoral® is administered with a buffer solution that, for adults, requires 150 ml of clean water. Dukoral can be given to all individuals over the age of 2 years. There must be a minimum of 7 days, and no more than 6 weeks, delay between each dose. Children aged 2 -5 require a third dose. Dukoral® is mainly used for travellers. Two doses of Dukoral® provide protection against cholera for 2 years.

Shanchol™ and Euvichol-Plus® have the same vaccine formula, produced by two different manufacturers. They do not require a buffer solution for administration. They are given to all individuals over the age of one year. There must be a minimum of two weeks delay between each dose of these two vaccines. Two doses of Shanchol™ and Euvichol-Plus® provide protection against cholera at least for three years, while one dose provides short term protection.

Shanchol™ is prequalified to be used in a Controlled Temperature Chain, an innovative approach to vaccine management allowing vaccines to be kept at temperatures outside of the traditional cold chain of +2°C to +8°C for a limited period of time under monitored and controlled conditions.

More information on Control Temperature Chain can be found here

Shanchol™ and Euvichol-Plus® are the vaccines currently available for mass vaccination campaigns through the Global OCV Stockpile. The stockpile is supported by Gavi, the Vaccine Alliance.

Based on the available evidence, the August 2017 WHO Position Paper on Vaccines against Cholera states that:

OCV should be used in areas with endemic cholera, in humanitarian crises with high risk of cholera, and during cholera outbreaks; always in conjunction with other cholera prevention and control strategies;

vaccination should not disrupt the provision of other high priority health interventions to control or prevent cholera outbreaks.

More than 100 million doses of OCV have been used in mass vaccination campaigns. The campaigns have been implemented in areas experiencing an outbreak, in areas at heightened vulnerability during humanitarian crises, and among populations living in highly endemic areas, known as "hotspots".

WHO response

In 2014 the Global Task Force on Cholera Control (GTFCC), with its Secretariat based at WHO, was revitalised. The GTFCC is a network of more than 50 partners active in cholera control globally, including academic institutions, non-governmental organisations and United Nations agencies.

Through the GTFCC and with support from donors, WHO works to:

promote the design and implementation of global strategies to contribute to capacity development for cholera prevention and control globally;

provide a forum for technical exchange, coordination, and cooperation on cholera-related activities to strengthen country capacity to prevent and control cholera;

support countries for the implementation of effective cholera control strategies and monitoring of progress;

disseminate technical guidelines and operational manuals;

support the development of a research agenda with emphasis on evaluating innovative approaches to cholera prevention and control in affected countries; and

increase the visibility of cholera as an important global public health problem through the dissemination of information about cholera prevention and control, and conducting advocacy and resource mobilization activities to support cholera prevention and control at national, regional, and global levels.

To strengthen GTFCC support to countries, in 2020 a Country Support Platform ( CSP) was established. The CSP, hosted by the International Federation of Red Cross and Red Crescent Societies (IFRC) provides multisectoral operational support as well as advocacy, coordination, and policy guidance necessary for countries to develop, fund, implement and monitor their NCPs effectively in alignment with the Global Roadmap.

More about the Global Task Force on Cholera Control (GTFCC) and the Country support Platform (CSP)

Ending Cholera: a Roadmap to 2030

In October 2017, GTFCC partners launched a strategy for cholera control Ending Cholera: A global roadmap to 2030. The country led strategy aims to reduce cholera deaths by 90% and to eliminate cholera in as many as 20 countries by 2030.

The Global Roadmap focuses on three strategic axes:

1. Early detection and quick response to contain outbreaks: the strategy focuses on containing outbreaks-wherever they may occur- through early detection and rapid multisectoral response including community, engagement, strengthening surveillance and laboratory capacity, health systems and supply readiness, and supporting rapid response teams.

2. A targeted multi-sectoral approach to prevent cholera recurrence: the strategy calls on countries and partners to focus on cholera "hotspots", the relatively small areas most heavily affected by cholera. Cholera transmission can be stopped in these areas through measures including improved WASH and through use of OCV.

3. An effective mechanism of coordination for technical support, advocacy, resource mobilisation, and partnership at local and global levels: The GTFCC provides a strong framework to support countries to intensify efforts to control cholera, building upon country-led cross-sectoral cholera control programs and supporting them with human, technical, and financial resources.

A resolution promoting control of cholera and endorsing "Ending Cholera: A global roadmap to 2030" was passed in May 2018 at the 71st World Health Assembly.
More about the strategy
Cholera Kits

To ensure efficient and effective deployment of necessary materials for the investigation and confirmation of cholera outbreaks, as well as the treatment of cholera patients, WHO has developed a set of cholera kits.

In 2016, after consultation with implementing partners, WHO revised the cholera kits to better meet field needs. There are 6 kits:

1 for investigation

1 with supplies for laboratory confirmation

3 for treatment at each of the community, peripheral and central levels

1 support kit with logistical materials including solar lamps, fencing, water bladders and taps.

Each treatment kit provides enough material to treat 100 patients. The revised cholera kits are designed to help prepare for a potential cholera outbreak and to support the first month of the initial response.

More about cholera kits

References

(1) Updated global burden of cholera in endemic countries.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455997/

Ali M, Nelson AR, Lopez AL, Sack D. (2015). PLoS Negl Trop Dis 9(6): e0003832. doi:10.1371/journal.pntd.0003832.

(2) The incubation period of cholera: a systematic review.
https://www.ncbi.nlm.nih.gov/pubmed/23201968
Azman AS, Rudolph KE, Cummings DA, Lessler J. J Infect. 2013;66(5):432-8. doi: 10.1016/j.jinf.2012.11.013. PubMed PMID: 23201968; PubMed Central PMCID: PMC3677557.

(3) Cholera Annual Report 2020 Weekly Epidemiological Record 37 September 2021, Vol 96, (pp 445-460).

(4) Cholera vaccines: WHO position paper - August 2017
http://apps.who.int/iris/bitstream/10665/258764/1/WER9234-477-498.pdf

Weekly Epidemiological Record 25 August 2017, No 34, 2017, 92, 477-500.

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Cholera is an extremely virulent disease. It affects both children and adults and can kill within hours if left untreated. Severe cases need rapid treatment with intravenous fluids and antibiotics.

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Simple and easy steps to take in preventing the spread of cholera

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Centers for Disease Control and Prevention

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To prevent cholera, you should wash your hands often and take steps to ensure your food and water are safe for use. The risk for cholera is greatly reduced for people in areas where cholera is spreading when these simple steps are followed:

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This article focuses on the impact cholera has had on Haiti. It takes a look at why Haiti was contaminated in the first place, and the UN response to that. The overall theme is lack of vaccines and a big lack of funding. Vaccines needed to be administered to those who don't have access to sanitary water first.

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Lebanon cholera: 'We're afraid of everything now' (2022)

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Lebanon cholera: 'We're afraid of everything now' (2022)

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This BBC articles focuses in on the reality of what this illness can do. Several stories are spoken sharing grief, confusion, and pain. They live in fear because this illness is all around them, and seemingly has no end.

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Mohamad Akel can't breathe. He heaves over onto his side, retching, and begs for the water he isn't allowed to drink.

He arrived at the hospital emergency ward from his home in Minyel just a few hours ago. The doctor suspects cholera.

"All my body aches, I have fever and chills," he groans. "Now I really can't take anything in. If I did it would go out again from here and here." He gestures first to his mouth, and then further down.

He hasn't got time for this. Mohamad is a farmer, and needs to be out working in his fields. He coughs again, rolling from side to side on the bed in pain. But he's determined to tell me who he blames.

"There is a Nobel prize for peace? Lebanon deserves the Nobel prize for failure. All of our politicians are corrupt. It's no surprise we got to this situation."

The country's political failures are tightly woven into this outbreak.

Despite elections in May, no new government has been formed. The national electricity grid provides just an hour of power a day, if that. The currency has lost around 90% of its value, and medicines can be hard to find. More than 80% of the population here is living in poverty.

Lebanon has collapsed from a reasonably affluent country into one at risk from the chaos that a preventable, treatable disease like cholera can cause.

It's transmitted through unclean water, and in a place where the most basic sanitation systems have broken down, the spread can be rapid.

The last Lebanese cholera case was three decades ago. It returned on 6 October. There've been hundreds of suspected cases since then, but because there aren't simple diagnostic tests the true figure could be thousands.

Now Lebanon is one of 29 countries to have reported outbreaks since January of this year.

Neighbouring Syria is already dealing with thousands of cases, and Afghanistan, Pakistan and Haiti are among those affected.

In the last five years fewer than 20 countries on average have reported cases, and the World Health Organisation has called 2022's rise in infections "unprecedented".

It's even had to suspend its two-dose cholera vaccine strategy because of a shortage in the global supply.

Cost of care

As I walk from room to room on the children's floor of the Abdallah Elrassi hospital, the patients keep getting younger.

Ziad Al Ali is five. He lies quietly, his brown eyes gazing at the ceiling.

Mira Sofan, a Syrian refugee, is 18 months old. Her drip needs replacing, but she's crying and thrashing as her mother tries to soothe her.

Jad Hussam Al Jundi was born just four months ago, and his sleeping body is a small dot on the expanse of white hospital bed. His proud new parents have brought him all the way here from Tripoli, nearly an hour away. They couldn't find treatment any closer to home.

The sound here is unlike a normal hospital ward. The silence isn't punctuated with the usual beeping and whirring of sophisticated machines. Each child has little more than a bag of intravenous fluid hanging quietly by the bed.

With the right care cholera is easily treatable. But the response has to be fast.

One Lebanese man was desperate to tell me about the difficulties he faced getting treatment for his daughter.

"They wouldn't take her unless we paid two million Lebanese lira [$50 according to the black market rate]. What should we do? Steal? Kill? We don't carry arms. We are poor".

The Lebanese government has now agreed to cover the medical costs for its citizens who contract cholera.

But for the country's around one million refugees - it's hard to know exactly how many live here - the situation is less clear-cut.

The UN refugee agency UNHCR provides for their medical care, but many Syrians fear having to pay for it themselves.

Sometimes it means they avoid going to hospital until the last minute. For a disease that moves as swiftly as cholera, that delay can be deadly.

River of brown water

The Abdallah Elrassi hospital is the only public hospital in Akkar, in Lebanon's north. This is the poorest part of the country. The hospital's Director, Dr Mohamad Khodreen, fears they could be overwhelmed by the growing outbreak.

"We have now dedicated 70% of our beds to cholera cases," he says.

"And after the Health Minister Firass Abiad visited here he asked us to provide even more. Soon we'll have around 120 beds. But this is a small hospital for a big area, and cases are increasing. If the problem isn't contained, we won't be able to cope".

Most parts of the country have now recorded cholera cases, and it's also been detected in the wastewater in the capital, Beirut.

Bebnine in the north has seen one of the biggest cholera outbreaks in Lebanon so far.

A man-made channel of brown water cuts right through the heart of the town. It's completely opaque, and looking into it you can't see even a hint of what lies below the surface.

Houses perch right next to the water's edge as it flows lazily downstream. One of them is home to Hussein Ali.

His brother, Hasan, died from cholera three days before we meet. His wife, niece and nephew are all being treated too.

"We don't know where we got infected from" he says. "Is it the air or the water? We are living in a state of panic, we are afraid of everything now."

His grief is still raw, and he wipes his face with his hand.

"I lost the most valuable person I had. He was my soulmate, my wingman. He was my friend all day long, we only separated at night to sleep."

Normally when there's a death, members of the community flock to pay their condolences. Average numbers can reach 1,000. But outside Hussein's home the brown plastic chairs remain stacked, and a tray of welcoming dates is almost untouched.

Hardly anybody visited the family, because they're too scared of catching cholera themselves.

The river of brown water often ends up being used to irrigate crops, and it's making the spread of cholera worse.

Homes have visible pipes leading up from the channel to bring water indoors, and others that hang out over it discharging household waste back in.

Umm Ahmad, her husband and children live on a smallholding, and have to grow produce for their landlord as part of their rent agreement.

In a few days they'll be digging fresh shoots into the brown earth beneath the polytunnels. She knows that there's a strong chance the pipes that water them will bring cholera from the stream.

But she tells me they have no choice.

"Of course I'm worried," she frowns. "My brother caught cholera and a number of our neighbours have died from it, including a young man just today. We try to avoid it but we don't always have a choice."

Ettie Higgins, the Deputy Representative in Lebanon of the UN children's agency UNICEF, says they'd been warning of a cholera outbreak for more than a year.

There were dangerous markers suggesting that if it transferred across from Syria, the dire conditions here would only aid its spread.

One big problem was the breakdown of Tripoli's wastewater treatment plant - another casualty of Lebanon's electricity crisis. It would normally deal with everything from human faeces to industrial waste from factories and slaughterhouses. But now there's nowhere for it to go.

"Normally this waste goes through an initial screening," Ms Higgins explains, "and it gets pumped out 1,600 metres [5,250 ft] into the sea. But because of the lack of fuel, they were unable to even pump it out to sea. So it was just being deposited directly onto the shoreline instead."

Cholera cases in Lebanon are still growing by the day, and the problems causing it are so numerous that they're a huge challenge to fix.

But until there are real, tangible improvements to the country's infrastructure, it's hard to see how this outbreak can be brought under control.

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Lebanon cholera: 'We're afraid of everything now'

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Mohamad Akel can't breathe. He heaves over onto his side, retching, and begs for the water he isn't allowed to drink. He arrived at the hospital emergency ward from his home in Minyel just a few hours ago. The doctor suspects cholera. "All my body aches, I have fever and chills," he groans.

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Cholera is one of many illnesses that lead to diarrhea, and when children are infected they struggle the most. The Bill and Melinda Gates Foundation is set on eliminating this disease by focusing cost-effective vaccines and advocacy as well. Because it is so deadly to children early and later on in life, providing service now can ensure long healthy lives.

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To eliminate diarrheal disease deaths in young children and to effectively control enteric fever as a public health problem.

Diarrheal infections kill more than 500,000 children under age 5 each year, primarily in lower-income countries.

In addition, enteric fever causes about 25,000 deaths in young children in countries with poor access to clean water and safe sanitation.

Enteric and diarrheal diseases are associated with stunting and impaired cognitive development as well as other long-term health problems.

We focus on vaccines as a cost-effective way to protect children from infection by pathogens that cause these diseases.

We support the goals of the integrated Global Action Plan for Pneumonia and Diarrhea, an effort led by the World Health Organization and UNICEF.

Our strategy

We focus on advancing the development and delivery of safe, affordable, and effective vaccines for the leading causes of enteric and diarrheal diseases in low- and lower-middle-income countries. We also support research on the global and regional burden of disease and the development of tools to model and assess disease transmission. This research helps inform decisions on when and how to deploy new interventions and expand the use of existing ones.

Areas of focus

We work with global partners to invest in new and improved vaccines that protect children against the major enteric and diarrheal disease pathogens and are safe and affordable. We work with the international community to support deployment of these vaccines in communities at risk of these diseases.

Diarrheal diseases are common in young children, leading to about 500,000 deaths worldwide every year. We focus on advancing the development and delivery of vaccines to combat these diseases, which disproportionately affect children in lower-income settings. Our efforts include investments in vaccines for rotavirus, the most common pathogen that causes moderate to severe diarrhea, and the leading bacterial causes of diarrheal diseases, Shigella and cholera. We also focus on typhoid, a disease affecting populations with less access to safe sanitation, clean water, and medical services.

Rotavirus. Rotavirus is the most common cause of diarrheal hospitalizations and deaths in children under age 5 in lower-income countries. Existing rotavirus vaccines have been shown to dramatically reduce the number of hospitalizations and deaths. The World Health Organization (WHO) recommends their use in all countries, particularly in places where diarrhea is a major cause of child mortality.

We work closely with Gavi, the Vaccine Alliance, and national governments to support the introduction and sustainable delivery of rotavirus vaccines in all infants globally and to ensure adequate supply and appropriate formulations, packaging, and labeling.

We also work with vaccine manufacturers in emerging economies such as India and Indonesia to invest in new oral rotavirus vaccines that will diversify the market, increase vaccine supply, and decrease costs.

Despite the success of current rotavirus vaccines, their effectiveness is often lower in low-resource settings than in middle- and high-income countries. The reasons include a condition called gut enteropathy that is associated with multiple other enteric infections, inflammation and malnutrition, high maternal antibody levels, and the microbiome. We are working with several partners to develop next-generation rotavirus vaccines that are more effective and can help increase vaccine access in low-income settings.

Cholera. Cholera kills as many as 120,000 people each year. At least 47 countries in sub-Saharan Africa and Asia have endemic cholera, which means the disease is consistently present. Several recent outbreaks in Nigeria, Yemen, South Sudan, Zimbabwe, Cameroon, and elsewhere have severely strained these countries' under-resourced health systems. For example, in 2021-2022, Nigeria experienced a surge in cholera cases, with thousands of cases and many deaths, highlighting the largest peak in disease in over a decade and showing the potential impact of outbreaks in endemic settings. A cholera outbreak in the Democratic Republic of the Congo between 2013 and 2017 resulted in more than 3,300 deaths. Simultaneous outbreaks of measles and Ebola overwhelmed the country's health system, demonstrating the importance of strong health systems that reach communities quickly with lifesaving tools such as oral cholera vaccines.

With support from our foundation and other international partners, WHO established a global oral cholera vaccine stockpile in 2013, which is managed by Gavi-a key milestone for cholera prevention and control. The Global Task Force on Cholera Control has facilitated the shipment of more than 100 million doses of cholera vaccine to more than 26 countries for use during outbreaks and humanitarian crises and in endemic areas. The cholera vaccine supply remains insufficient, however, so we support additional vaccine manufacturers in emerging economies in producing more. Stable vaccine supply should lead to more competitive pricing and spur additional demand from countries with a high burden of cholera. Several countries have implemented successful cholera vaccination campaigns and expanded their requests for additional doses in subsequent years.

We also support the development of evidence-based policy guidelines for oral cholera vaccine use in outbreak settings, as well as better data collection to build a case for the targeted use of cholera vaccines in endemic or "hot spot" areas.

Typhoid. Every year, typhoid infections kill nearly 100,000 people, primarily children in lower-income countries. In recent years, cases of antibiotic-resistant typhoid have increased, making the disease even more dangerous.

Typhoid conjugate vaccines (TCVs) offer a solution. First developed in 2015 with our support, these vaccines are a game-changer for preventing the spread of typhoid. They are the first typhoid vaccines to be approved for use in children under age 2-one of the groups most vulnerable to typhoid. They also provide long-lasting immunity and reduce the need for antibiotics, which helps prevent drug-resistant strains of typhoid from emerging and spreading. TCVs were developed and are now manufactured in South Asia and Southeast Asia, where the burden of typhoid is greatest.

More than 36 million children have already received a dose of TCV, and the results have been promising and remarkably consistent: Studies have shown that TCVs can prevent 80% or more of typhoid cases. The vaccine has been included in routine childhood immunization programs in countries including Pakistan, Liberia, and Zimbabwe, and more countries are planning to introduce the vaccine soon. TCVs are helping us get closer to a world where no child dies from a vaccine-preventable disease.

Shigella. Shigella is a common bacterial pathogen in most low-income regions, with more than 93,000 deaths in children under age 5 in 2019. Shigella infection is also associated with significantly reduced growth. Due to its growing resistance to multiple drugs, therapeutic options are limited, which makes developing a vaccine a high priority.

No vaccine is currently available for Shigella, but we are working with public health partners, biotechnology companies, and in-country vaccine manufacturers to accelerate the development process, including investing in early-stage candidates and analytical tools.

We work to generate evidence that can help us understand enteric and diarrheal disease burden, evaluate the impact of interventions (including assessing the effects of vaccine introductions), and plan future investment priorities.

We support several surveillance networks, including for global pediatric diarrheal disease surveillance through WHO and its regional offices, typhoid surveillance in South Asia and Africa, and the Child Health and Mortality Prevention Surveillance (CHAMPS) network, a global network of foundation-funded study sites.

We also invest in the development of affordable tools to assess disease burden, such as environmental surveillance, and we work with partners to model data to ensure their translation into rapid public health action. For example, we work with researchers at Imperial College London and partners at the Christian Medical College in Vellore, India; Malawi Liverpool Wellcome Trust in Blantyre, Malawi; and Kwame Nkrumah University of Science and Technology in Kumasi, Ghana, to validate environmental surveillance tools for typhoid alongside clinical surveillance. More recently, building on these efforts, our partners have implemented SARS-CoV-2 surveillance and environmental surveillance of multiple respiratory and enteric pathogens using a promising low-cost platform for enhancing outbreak and pandemic preparedness.

We work to ensure that child health is a priority at the national and global levels, with sufficient funding and political will to increase the delivery of vaccines, preventive interventions, and treatments for enteric and diarrheal diseases. Our efforts include supporting the goals of the integrated Global Action Plan for Pneumonia and Diarrhea and the Immunization Agenda 2030. Our core partners in this work include Gavi, UNICEF, WHO, PATH, the International Federation of the Red Cross, and Save the Children.

Why focus on enteric and diarrheal diseases?

Why focus on enteric and diarrheal diseases?

Enteric and diarrheal diseases are the second leading infectious causes of death for young children in lower-income countries, killing more than 500,000 children under age 5 each year. Children who survive often face repeated diarrheal infections in the early years of life, which can lead to serious, lifelong health problems. Evidence suggests an association between repeated infections and poor nutrient absorption, weaker immune response to oral vaccines, stunted growth, and impaired cognitive development.

Typhoid fever and its cousin, paratyphoid fever, are significant public health problems in South Asia, Southeast Asia, and many parts of sub-Saharan Africa. Typhoid stands out as a neglected disease: Children living in poor, densely populated urban areas without clean water and sanitation infrastructure suffer the highest rates of typhoid and paratyphoid fever. Typhoid fever is becoming an even more dangerous public health problem due to rapid and unregulated urbanization in developing countries, combined with the emergence of multidrug-resistant typhoid.

Research, funding, and political commitment to address these diseases are lacking in many places, which results in a dearth of critical information about the pathogens and the environmental factors that increase their occurrence. Effective and affordable tools for prevention and treatment exist, but most do not reach the poorest communities and regions.

The past 20 years have seen a significant decline in the number of children under age 5 dying from diarrheal diseases, in part due to socioeconomic development, improved water and sanitation systems, and better access to vaccines, diagnostics, and treatments. However, too many children still perish from infections that are entirely preventable or treatable. Prevention efforts that focus on vaccines in the short term and improvements in water, sanitation, and hygiene in the longer term can significantly reduce both suffering and death from these diseases.

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Our partners

The following is an illustrative list of our grantees. It excludes specific vaccine manufacturers, with whom we engage most often through product development partners.

Related programs

The team working to prevent and reduce pneumonia, the leading cause of death for kids under 5

Water, Sanitation & Hygiene

The team supporting the widespread use of safe and sustainable sanitation

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Enteric and Diarrheal Diseases | Gates Foundation

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To eliminate diarrheal disease deaths in young children and to effectively control enteric fever as a public health problem. Diarrheal infections kill more than 500,000 children under age 5 each year, primarily in lower-income countries. In addition, enteric fever causes about 25,000 deaths in young children in countries with poor access to clean water and safe sanitation.

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Mother immunizes daughter against cholera as she fears she could die

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Global Cholera Response &  Preparedness 

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Global Cholera Response &  Preparedness 

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This article focuses on countries mitigation strategies on cholera. It took data from how these countries implemented sustainable development goals (SDG's), millennium development goals (MDG's), and their quality of water.

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Global mapping of cholera Vibrio and outbreaks in the Pre-Millennium Development Goals (MDG):Sustain

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Past years the cholera cases have been plummeting, but recently in 2022, cholera has come back and expected to rise in upcoming years. Many countries are being effected and continue to struggle to receive vaccines.

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Three countries, this week alone, have reported outbreaks, WHO cholera team leader Philippe Barboza told reporters at a press conference on Friday.

For the first time, WHO is asking donors for help to fight the outbreaks, he said.

Right now, 22 countries across the world are fighting outbreaks of the acute diarrhoeal infection caused by eating or drinking contaminated food or water. Cholera cases climbed in 2022, following years of falling numbers of cases, and the trend is expected to continue into this year, he said.

He said cases have been reported in five of the six regions where WHO operates. The latest WHO global overview published in early February showed the situation has further deteriorated since 2022.

Poverty, disasters, conflict and climate change consequences continue to be driving factors alongside a lack of access to safe water and sanitation, Dr. Barboza said.

Limited vaccine supplies

"An unprecedented situation requires an unprecedented response," he said, drawing attention to the limited availability of vaccines, medicines, and testing kits.

Only 37 million doses are available in 2023, he said. More doses are expected to be available by next year.

As a result of the current global surge, WHO is, for the first time ever, appealing to donors to support a $25 million fund to help to address cholera outbreaks and save lives, he said.

Prevention is key, he said, noting that nearly half of the world lacks access to safely managed sanitation.

"Access to safe drinking water and sanitation are internationally recognized human rights," he said. " Making these rights a reality will also end cholera."

Outbreak in Africa

An exponential rise in the number of cholera cases in Africa includes an outbreak in Mozambique, which is also grappling with severe storms brought on by cyclone Freddy. The first case of cholera in the current outbreak was reported to the Ministry of Health and WHO from Lago district in Niassa province in September.

As of 19 February, Mozambique reported a cumulative total of 5,237 suspected cases and 37 deaths. All six cholera-affected provinces are flood-prone areas, and WHO anticipates that more will be affected as the rainy season continues.

Considering the frequency of cross-border movement and the history of cross-border spread of cholera during this outbreak, WHO considers the risk of further disease spread as very high at national and regional levels.

An estimated 26,000 cases and 660 deaths have been reported as of 29 January 2023 in 10 African countries facing outbreaks since the beginning of the year, WHO said. In 2022, nearly 80,000 cases and 1,863 deaths were recorded from 15 affected countries.

Multiple countries affected

Neighbouring Malawi is facing the deadliest cholera outbreak in two decades, and cases are being reported in other countries, including Ethiopia, Kenya and Somalia, WHO reported.

The UN health agency said challenges include climate change, which has led to drought or flooding in parts of Africa, resulting in increased population displacement and reduced access to clean water.

Worldwide, people in Haiti, India, Pakistan, the Philippines and Syria, among others, are also affected by outbreaks.

Global threat

Cholera remains a global threat to public health, WHO said. In 2017, affected countries, donors, and partners of the Global Task Force on Cholera Control launched a renewed global cholera control strategy, Ending Cholera: A Global Roadmap to 2030. It aims at reducing cholera deaths by 90 per cent over the next decade.

While the number of cases had been declining, WHO remains concerned about the current surge. Researchers estimate that every year, there are between 1.3 and 4 million cases and 21,000 to 143,000 deaths worldwide due to the infection.

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Over 1 billion in 43 nations at risk amid cholera outbreaks, WHO says

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Three countries, this week alone, have reported outbreaks, WHO cholera team leader Philippe Barboza told reporters at a press conference on Friday. For the first time, WHO is asking donors for help to fight the outbreaks, he said. Right now, 22 countries across the world are fighting outbreaks of the acute diarrhoeal infection caused by eating or drinking contaminated food or water.

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In the fight against Cholera, ACTED works to stem an epidemic

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In the fight against Cholera, ACTED works to stem an epidemic

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Agency for Technical Cooperation and Development or ACTED is a non-governmental organization that provided help when it was needed most. Cholera kits were handed out to those who needed it, and in doing this they can stay away from the cholera infected water.

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In the fight against Cholera, ACTED works to stem an epidemic - ACTED

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Since the beginning of the Yemen conflict, access to clean water has emerged as a life-or-death issue for millions of people. Yemen's sizeable population of over three million internally displaced persons remain the worst affected due to reduced access to healthcare. Populations are forced to rely on overexploited and unsafe water points, often damaged or destroyed by the conflict.

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Vaccines are in short supply amid global cholera surge (2022)

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Vaccines are in short supply amid global cholera surge (2022)

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This article takes a look at choleras recent resurgence. The outbreaks have been linked to warm weather and global climate change. The easiest way to combat the illness is an oral hydration solution, but administered quickly. These are hard to receive in such big surplus as cholera is always present.

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Vaccines are in short supply amid global cholera surge | Science | AAAS

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The (GTFCC) or Global Task Force on Cholera Control was created in hopes to reduce the cholera deaths by 90% in the near future. It is comprised of a collection of governmental/ non-governmental organizations, and agencies that coordinate combative strategies. Recently they came together to make a new cholera control strategy guide - The Ending Cholera - A Global Roadmap to 2030.

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The Global Task Force on Cholera Control (GTFCC) is a network of governmental and non-governmental organizations, UN agencies, and scientific partner institutions that helps coordinate activities for cholera control. The Secretariat of the GTFCC is hosted in WHO. In October 2017, cholera-affected c…