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The newspaper headline during the Cholera pandemic including health measures and advisories.

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1817: The first ever cholera pandemic started during the outbreak in 1812-1821 in India, specifically in Ganges delta, and was known as “Asiatic cholera” (Azizi & Azizi, 2010).

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December 2019: The first case of a novel coronavirus (SARS-CoV-2) was first reported in Wuhan, China.

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Cholera - Office of NIH History and Stetten Museum

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Cholera has caused a total of seven pandemics since the 18th century and is present up until the 20th century.

1st: 1817 - The first ever cholera pandemic started during the outbreak in 1812-1821 in India, known as “Asiatic cholera”.

2nd: 1829 - The second pandemic also began in India and has spread throughout China, Europe, and America and lasted until 1851.

3rd: 1852 - The next year continued with the third cholera pandemic until 1860 and was considered as the deadliest among all seven pandemics. This pandemic mainly took place in Russia.

4th: 1863 - The fourth pandemic was transmitted through Indian Muslims who visited Mecca and was widespread throughout the Middle East until 1875.

5th: 1881 - The fifth lasted until 1896 in India and has spread throughout Europe, affecting Germany the most.

6th: 1899 - After three years, the sixth killed around 800,000 people in India and continued to grow in the Middle East until 1923.

7th: 1961 - The seventh and current cholera pandemic began in Indonesia.

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The first Vietnamese case of COVID-19 acquired from China.

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December 2019: Cases of a novel coronavirus (SARS-CoV-2) were first reported in Wuhan, China.

January 2020: The World Health Organization (WHO) declared the COVID-19 outbreak a Public Health Emergency of International Concern.

March 2020: The WHO declared COVID-19 a pandemic as cases surged globally.

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The Weekly Epidemiological Update provides an overview of the global, regional and country-level COVID-19 cases and deaths, highlighting key data and trends; as well as other pertinent epidemiological information concerning the COVID-19 pandemic. The COVID-19 Weekly Operational Update reports on WHO and partners' actions in response to the pandemic.

Weekly Epidemiological and Operational updates August 2021

Weekly Epidemiological and Operational updates July 2021

Weekly Epidemiological and Operational updates June 2021

Weekly Epidemiological and Operational updates May 2021

Weekly Epidemiological and Operational updates April 2021

Weekly Epidemiological and Operational updates March 2021

Weekly Epidemiological and Operational updates February 2021

Weekly Epidemiological and Operational updates January 2021

Weekly Epidemiological and Operational updates December 2020

Weekly Epidemiological and Operational updates November 2020

Weekly Epidemiological and Operational updates October 2020

Weekly Epidemiological and Operational updates September 2020

Weekly Epidemiological and Operational updates August 2020

Situation reports February 2020

Situation reports January 2020

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Coronavirus Disease (COVID-19) Situation Reports

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The Weekly Epidemiological Update provides an overview of the global, regional and country-level COVID-19 cases and deaths, highlighting key data and trends; as well as other pertinent epidemiological information concerning the COVID-19 pandemic. The COVID-19 Weekly Operational Update reports on WHO and partners' actions in response to the pandemic.

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1817 - 1961: Cholera has caused a total of seven pandemics since the 18th century with the seventh occurring to this day. However, the global incidence of cholera has decreased during the late 1990s. Currently, cholera remains common in some parts of Africa and Asia and is considered endemic throughout many countries (World Health Organization, 2023).

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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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May 2023: The WHO declared an end to COVID-19 as no longer a public health emergency.

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COVID-19 pandemic no longer a 'global health emergency'

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PH gov't defends response vs COVID-19 | ANC

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An informative publication material from DOH about cholera awareness

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2022 - DOH is continuously implementing programs on water and sanitation in addressing Food and Water Borne Diseases in the Philippines through allocation of resources by IACEH member agencies. Through CHDs and LGUs, the department is also presently implementing drinking water quality surveillance programs and sanitation programs that eliminate open defecation processes and ensure proper feces and sewer waste disposal (OCHA Web, 2022).

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The implementation of ECQs throughout barangays during the pandemic

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QThroughout 2020: Countries implemented various measures such as lockdowns, social distancing, mask mandates, and travel restrictions to control the spread of the virus.

May - June 2020: The Malacañang placed the country under GCQ on May 16 except National Capital Region (NCR), Laguna, and Cebu City, which are under MECQ.

July - August 2020: The Malacañang stated that Metro Manila will maintain its GCQ status after the government noted effective compliance to protocols in slowing down the doubling rate of COVID-19 cases.

September - October 2020: Metro Manila would stay under GCQ until Sept. 30.

November - December 2020: President Duterte stated at that Metro Manila, including six other areas would follow under GCQ for the whole month of November.

May - August 2021 - The IATF has mandated all travelers, to be quarantined for 14 days upon the arrival.

September - October 2021 - The Malacañang announced that the National Capital Region, Bataan, and Laguna will remain under MECQ from Sept. 1 to 7, with the same additional restrictions.

November 2021 - As of November 2, the Philippines has registered only 2,303 new COVID-19 cases, which is the lowest single-day new infection rate recorded for the past eight months. The mayors of Metro Manila decided to lift the curfew hours in the National Capital Region for the first time ever since the COVID-19 outbreak.

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1. Quarantine measures were often implemented to isolate infected individuals and prevent the spread of the disease to unaffected areas.

2. Efforts were made to improve sanitation and hygiene practices, including the construction of sewage systems, provision of clean water sources, and proper waste disposal.

3. Public awareness campaigns were conducted to educate the population about the importance of hygiene, safe water consumption, and proper food handling to prevent cholera transmission.

4. Isolation facilities and treatment centers were established to provide medical care to cholera patients and prevent further transmission of the disease.

5. Surveillance systems were established to monitor the spread of cholera and identify new cases promptly. Health authorities encouraged the reporting of suspected cases to enable rapid response and control measures.

6. Travel restrictions were sometimes imposed to limit the movement of people from affected areas to prevent the spread of cholera to unaffected regions.

7. Medical interventions such as the administration of oral rehydration therapy and other supportive treatments were provided to manage cholera cases and reduce mortality rates.

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Late 2020 and 2021: Vaccines against COVID-19 were developed and rolled out globally, providing hope for controlling the pandemic.

COVID-19 vaccines have been developed and authorized for emergency use worldwide. The best vaccine for an individual depends on factors such as age, underlying health conditions, and vaccine availability in their region. Some of the widely used vaccines include Pfizer-BioNTech, Moderna, AstraZeneca, Johnson & Johnson's Janssen, Sinovac, Sinopharm, and Covaxin. All authorized vaccines have demonstrated efficacy in preventing severe illness, hospitalization, and death from COVID-19. It's essential to get vaccinated with the available options and to follow guidance from healthcare authorities.

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Global Perspective: Emphasis on Health and Sanitation Practices

Cholera is a disease that started due to poor sanitation of the public community and has prevailed to this day since the 18th century. It has spread globally and has killed millions of people throughout different countries. With its incidence mostly evident in areas of poverty, cholera has become an indication of inadequate provision of basic sanitation, water safety, and effective urbanization. Cases of cholera remain high, with an estimate of 1.3 to 4 million people acquiring the disease worldwide, which continues to spread caused by the limited resources necessary for both prevention and treatment of the disease (Centers for Disease Control and Prevention, 2022).

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Global Perspective: Emphasis on Health and Sanitation Practices

Life during the COVID-19 pandemic has been characterized by various challenges and changes. People have had to adapt to new norms such as wearing masks, practicing social distancing, and frequent handwashing to reduce the spread of the virus. Many have experienced disruptions to work, business, education, travel, and social activities due to lockdowns, quarantines, and restrictions implemented to curb the spread of the virus. Remote work and virtual schooling have become more common, while industries such as healthcare, grocery, and delivery services have faced increased demand. Mental health concerns have also been prominent, with feelings of isolation, anxiety, and stress affecting many individuals. Despite these challenges, communities have come together to support one another, and there has been a collective effort to develop vaccines and implement public health measures to overcome the pandemic.

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Local Perspective: Restrictive Approach

During the Spanish era, misinformation and propaganda has led to a poorly-managed community and disease management. Misinformation that claims hidden intents of the colonials has spread throughout communities and has led to mistrust and propagandas. The neglect of the government to emphasize on health education and awareness in Filipinos has also led to barriers related to cultural and religious differences and has only led to disagreements and miscoordination among the citizens (Acevedo, 2021). Due to the locals’ incompliance with proposed health measures, the government resorted to abuse by forcible administration of medicines in detention camps and the burning of the Farola district.

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Local Perspective: Restrictive Approach

The COVID-19 pandemic has raised issues revealing the incompetence of the Philippine government concerning its management of the disease within the country. Quarantine measures implemented by the government were perceived and treated as more of a public order than a health concern. Citizens who did not abide by community quarantine protocols were arrested, detained, or shot.

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Ineffective Measures

The implementation of preventive and containment measures were ineffective partly due to the negligence and failure of the authorities to focus on health information dissemination and education and quick and responsive actions in response to the emerging cases (PH Movement, 2021).

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Ineffective Measures

The COVID-19 pandemic has revealed the gaps and inconsistencies that has led to the failure of measures that were intended for greater purposes.

1. Testing and contract tracings were too slow as evidenced by the unresponsive management of the DOH despite urgent calls from groups who requested mass testing.

2. The Philippines was cited to have the longest lockdown in the world despite consistent implementation of quarantine variations. Although restrictive measures were implemented as prevention control, medical, livelihood, and economical support were lacking. Ordinary workers plead hunger and desperation due to the inability to work in the midst of quarantine.

3. The inaccessibility of healthcare services especially to the public became a reflection of the inadequate resources and poor allocation management. Among the 1,845 COVID-19 referral and accepting

hospitals, only 73 are public hospitals. Infection surges became a risk that came along this issue. A major lack of Personal Protective Equipment (PPE) was also evident despite its increasing demand in hospitals.

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Download the file to view the reference list.