# data[].attributes.body
Cholera impact’s many poor places around the world but is mostly in Africa. It is a disease that is a public health hazard. It spreads by unsanitary conditions and not enough clean water, and since Africa has poorer places, it would be easier for the disease to spread.

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What can be done to prevent the spread of cholera?

A multifaceted approach is key to controlling cholera and reducing deaths. First and foremost, ensuring that every child has access to safe drinking water and adequate sanitation is essential. It's also important that children in communities at risk have access to the WHO pre-qualified oral cholera vaccines.

Furthermore, community engagement plays an important role. Effective and engaging programmes can help to promote protective hygiene measures such as handwashing with soap and the safe disposal of faeces.

Additionally, given that cholera is an easily treatable disease, quick access to treatments during an outbreak, including oral rehydration solution, zinc and antibiotics is crucial. With early and proper treatment, the fatality rate should remain below one per cent.

Effective surveillance systems are also necessary to monitor and control the spread of cholera. The surveillance data gathered should be translated into accessible information that can be used effectively at a local, national and global level.

Are there vaccines available to prevent cholera?

There are currently three World Health Organization pre-qualified oral cholera vaccines: Dukoral, Shanchol and Euvichol-Plus. In order to be fully protected, all of these vaccines require two doses. The International Coordinating Group (ICG), which UNICEF is a member of, manages the global stockpile of oral cholera vaccines. The group has conducted mass vaccination campaigns resulting in more than 100 million doses of oral cholera vaccines being administered. These campaigns have focused on areas experiencing an outbreak, particularly in highly endemic areas known as "hotspots" and in areas at increased vulnerability during humanitarian crises.

Where in the world are we seeing cholera outbreaks?

In recent years, we've seen a surge in the number of cholera outbreaks globally. 30 countries faced cholera outbreaks in 2022 - an alarming 145 per cent average increase from the previous five-year average. Countries like Lebanon and Syria reported cholera for the first time in decades.

Meanwhile, an outbreak in Haiti in 2022 had a significant impact on children. There have been thousands of suspected cases, resulting in hundreds of deaths in that country. UNICEF has warned that about 40 per cent of the cases in Haiti are among children. The country is dealing with the aftermath of natural disasters, political instability, continued clashes between armed groups and a deepening nutrition crisis.

Furthermore, in early 2023, Malawi reported that it was experiencing its deadliest cholera outbreak in recorded history. With limited resources and overburdened health systems, health workers in the country are stretched to their limits. The outbreak has impacted all 29 districts in Malawi with thousands of children contracting cholera. In East and Southern Africa, outbreaks continue to spread across borders with multiple countries experiencing a cholera epidemic.

In addition to the spread of cholera in Africa and the crisis in Haiti, we've also witnessed recent cholera outbreaks in the Middle East. Thousands of cases have been detected, which has resulted in dozens of preventable deaths. Other neighboring countries are at significant risk.

UNICEF is working tirelessly to respond to these outbreaks in these impacted countries and regions.

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Cholera is endangering children globally

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Learn why outbreaks are occurring and how UNICEF is responding

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Cholera disease is significant because it is mainly affecting children, and it is known to be a global public health issue. Cholera causes numerous deaths per year, around 143,000. As for this disease affecting people it is also significant as it affects the economy. This disease has affected the economy for the decrease of productivity because of premature passing. The cost of this ended up being US900 million in 2015. If the cholera disease keeps on getting worse, many parts of Africa will suffer.

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Cholera is a dangerous bacterial disease that takes around 12 hours to 5 days for someone to show signs of it. It is very dangerous and if not treated it will cause someone to have dehydration. Chlorella is a problem because of the death rate and it affects mostly poor places which do not have access to good healthcare. In Africa the death rate is 1.8 percent.

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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.

# data[].attributes.attachment_link.description
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.

# data[].attributes.body
Cholera began swarming around the world in the 19th century and was seen in Africa in 1971. Many different cholera pandemics managed to kill many people and the current pandemic has begun to damage people in Africa.

# data[].attributes.attachment_link.readable_text
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.

# data[].attributes.attachment_link.description
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.

# data[].attributes.attachment_caption
A vaccine tent filled with the cholera vaccine

# data[].attributes.headline
What are some possible solutions to this issue? And a solution that you created.

# data[].attributes.subject
What are some possible solutions to this issue? And a solution that you created.

# data[].attributes.body
Cholera is very easily treated, a treatment option for children is with oral rehydration solution (ORS). Getting treatments as early as possible will maintain the fatality rate below one percent. The type of treatments people can receive are these three cholera vaccines, Dukoral, Shanchol and Euvichol. For these vaccines to work two doses are required to gain full protection.

# data[].attributes.headline
What are some possible solutions to this issue? And a solution that you created.

# data[].attributes.subject
What are some possible solutions to this issue? And a solution that you created.

# data[].attributes.body
To prevent this disease from spreading, communities can partake in volunteering programs that help create the goal for secure hygiene protocols. Some of these goals are to wash your hands with soap and to remove feces to protect the citizens. To prevent this disease from spreading citizens should set in protocols annual checkups for this disease. This then helps prevent the spread and if someone were to catch this disease the doctors would be able to see this earlier and give cures to this ill patient. A solution we have created is the annual cholera vaccine. If you are a citizen in Africa you are obligated to receive this vaccine annually. So, you will not catch this disease, and this will prevent the spreading.

# data[].attributes.attachment_caption
This shows ways on how to prevent the cholera disease

# data[].attributes.attachment_link.title
Mother immunizes daughter against cholera as she fears she could die

# data[].attributes.attachment_link.readable_text
Please click here if you are not redirected within a few seconds.

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

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why is chlorea signinficsant - Google Search

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Sep 12, 2017 — It devastated Asia, Europe, North America and Africa, killing 23,000 people in Great Britain alone in 1854, the worst single year of cholera.

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What can be done to prevent the spread of cholera?

A multifaceted approach is key to controlling cholera and reducing deaths. First and foremost, ensuring that every child has access to safe drinking water and adequate sanitation is essential. It's also important that children in communities at risk have access to the WHO pre-qualified oral cholera vaccines.

Furthermore, community engagement plays an important role. Effective and engaging programmes can help to promote protective hygiene measures such as handwashing with soap and the safe disposal of faeces.

Additionally, given that cholera is an easily treatable disease, quick access to treatments during an outbreak, including oral rehydration solution, zinc and antibiotics is crucial. With early and proper treatment, the fatality rate should remain below one per cent.

Effective surveillance systems are also necessary to monitor and control the spread of cholera. The surveillance data gathered should be translated into accessible information that can be used effectively at a local, national and global level.

Are there vaccines available to prevent cholera?

There are currently three World Health Organization pre-qualified oral cholera vaccines: Dukoral, Shanchol and Euvichol-Plus. In order to be fully protected, all of these vaccines require two doses. The International Coordinating Group (ICG), which UNICEF is a member of, manages the global stockpile of oral cholera vaccines. The group has conducted mass vaccination campaigns resulting in more than 100 million doses of oral cholera vaccines being administered. These campaigns have focused on areas experiencing an outbreak, particularly in highly endemic areas known as "hotspots" and in areas at increased vulnerability during humanitarian crises.

Where in the world are we seeing cholera outbreaks?

In recent years, we've seen a surge in the number of cholera outbreaks globally. 30 countries faced cholera outbreaks in 2022 - an alarming 145 per cent average increase from the previous five-year average. Countries like Lebanon and Syria reported cholera for the first time in decades.

Meanwhile, an outbreak in Haiti in 2022 had a significant impact on children. There have been thousands of suspected cases, resulting in hundreds of deaths in that country. UNICEF has warned that about 40 per cent of the cases in Haiti are among children. The country is dealing with the aftermath of natural disasters, political instability, continued clashes between armed groups and a deepening nutrition crisis.

Furthermore, in early 2023, Malawi reported that it was experiencing its deadliest cholera outbreak in recorded history. With limited resources and overburdened health systems, health workers in the country are stretched to their limits. The outbreak has impacted all 29 districts in Malawi with thousands of children contracting cholera. In East and Southern Africa, outbreaks continue to spread across borders with multiple countries experiencing a cholera epidemic.

In addition to the spread of cholera in Africa and the crisis in Haiti, we've also witnessed recent cholera outbreaks in the Middle East. Thousands of cases have been detected, which has resulted in dozens of preventable deaths. Other neighboring countries are at significant risk.

UNICEF is working tirelessly to respond to these outbreaks in these impacted countries and regions.

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Cholera is endangering children globally

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Learn why outbreaks are occurring and how UNICEF is responding

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What can be done to prevent the spread of cholera?

A multifaceted approach is key to controlling cholera and reducing deaths. First and foremost, ensuring that every child has access to safe drinking water and adequate sanitation is essential. It's also important that children in communities at risk have access to the WHO pre-qualified oral cholera vaccines.

Furthermore, community engagement plays an important role. Effective and engaging programmes can help to promote protective hygiene measures such as handwashing with soap and the safe disposal of faeces.

Additionally, given that cholera is an easily treatable disease, quick access to treatments during an outbreak, including oral rehydration solution, zinc and antibiotics is crucial. With early and proper treatment, the fatality rate should remain below one per cent.

Effective surveillance systems are also necessary to monitor and control the spread of cholera. The surveillance data gathered should be translated into accessible information that can be used effectively at a local, national and global level.

Are there vaccines available to prevent cholera?

There are currently three World Health Organization pre-qualified oral cholera vaccines: Dukoral, Shanchol and Euvichol-Plus. In order to be fully protected, all of these vaccines require two doses. The International Coordinating Group (ICG), which UNICEF is a member of, manages the global stockpile of oral cholera vaccines. The group has conducted mass vaccination campaigns resulting in more than 100 million doses of oral cholera vaccines being administered. These campaigns have focused on areas experiencing an outbreak, particularly in highly endemic areas known as "hotspots" and in areas at increased vulnerability during humanitarian crises.

Where in the world are we seeing cholera outbreaks?

In recent years, we've seen a surge in the number of cholera outbreaks globally. 30 countries faced cholera outbreaks in 2022 - an alarming 145 per cent average increase from the previous five-year average. Countries like Lebanon and Syria reported cholera for the first time in decades.

Meanwhile, an outbreak in Haiti in 2022 had a significant impact on children. There have been thousands of suspected cases, resulting in hundreds of deaths in that country. UNICEF has warned that about 40 per cent of the cases in Haiti are among children. The country is dealing with the aftermath of natural disasters, political instability, continued clashes between armed groups and a deepening nutrition crisis.

Furthermore, in early 2023, Malawi reported that it was experiencing its deadliest cholera outbreak in recorded history. With limited resources and overburdened health systems, health workers in the country are stretched to their limits. The outbreak has impacted all 29 districts in Malawi with thousands of children contracting cholera. In East and Southern Africa, outbreaks continue to spread across borders with multiple countries experiencing a cholera epidemic.

In addition to the spread of cholera in Africa and the crisis in Haiti, we've also witnessed recent cholera outbreaks in the Middle East. Thousands of cases have been detected, which has resulted in dozens of preventable deaths. Other neighboring countries are at significant risk.

UNICEF is working tirelessly to respond to these outbreaks in these impacted countries and regions.

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Cholera is endangering children globally

# data[].attributes.attachment_link.description
Learn why outbreaks are occurring and how UNICEF is responding

# data[].attributes.attachment_link.readable_text
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.