Cholera is not convenient, but technologies to control it should be

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David A. Sack, MD

Professor | Johns Hopkins Bloomberg School of Public Health
Water collection in east Africa. Photo: Lorenz Von Seidlein

Water collection in east Africa. Photo: Lorenz Von Seidlein

I was talking with a health official in Africa this week about an outbreak of cholera in his country.  I asked if vaccine had been considered as a response to the outbreak.  He responded: vaccination would not be possible in this area because it is too remote; the people are farmers living in scattered villages.

 Also, the area is recently recovering from civil war.  It would be too difficult to reach them with vaccine. Finally, he believes that fortunately, the outbreak is not spreading.
In considering his very realistic response, I had to agree.  It would indeed be too difficult to reach this population with oral cholera vaccine.  The vaccine currently requires a cold chain and a trained field team mobilized to this remote area to administer the vaccine.  However, it is difficult to verify the health official’s claim that the cholera outbreak is not spreading; monitoring the spread of cholera is extremely challenging, as confirmation of cases requires special bacteriological supplies and well-equipped microbiology laboratories with trained technicians.  
How to handle this mismatch between actual needs and the practical use of current tools for cholera surveillance, prevention, and control?  
We have an effective, safe vaccine which can easily be taken by mouth.  It is prequalified by the World Health Organization and is now available for free from a global stockpile.  But it does no good for the remote farmers who will never receive it.  Similarly, we have sensitive microbiology methods to monitor the spread of cholera, but they will not be applied in this remote area where the disease is occurring.  
Cholera is not a “convenient” disease, but practical strategies and technologies should be developed to monitor and control the disease for those vulnerable people living in these “inconvenient locations.”    
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