The Coalition for Cholera Prevention and Control: Forging Consensus to End Cholera Deaths Globally

The Task Force for Global Health is committed to the idea that all lives have equal value and everyone should have equal access to the means for good health, including vaccines. Driven by this commitment, The Task Force uses a powerful collaborative model to address the greatest health needs of the world’s poor.

Cholera is a water-borne disease that disproportionally affects the world’s poor and carries with it stigma for countries affected by the disease. It is an acute diarrheal infection, usually spread through contaminated water, that causes severe diarrhea and dehydration. Cholera is responsible for an estimated 100,000 deaths each year. Around the world, the poorest and most vulnerable populations, including those living in the midst of humanitarian crises, conflicts, and war, bear the heaviest burdens of the disease. Despite proven effective interventions to prevent and control cholera, more than one million cases occur each year.

In 2012, with funding and support from the Bill & Melinda Gates Foundation, The Task Force convened key cholera stakeholders and launched the Coalition for Cholera Prevention and Control (CCPC or the Coalition) to stop cholera transmission and end cholera deaths globally.

The Challenge

In the 1990s, the number of deaths attributed to cholera declined considerably as a result of the use of oral and intravenous rehydration solutions, antibiotics, and zinc. The availability of safe drinking water, proper disposal of human waste, and hygiene (also known as Water, Sanitation and Hygiene or WaSH) ensured that many regions of the world, including Europe, North, South, and Central America, completely eliminated the disease. However, cholera has continued to thrive in areas of the world that lack proper sanitation and access to potable water and, in particular, in humanitarian emergencies.

The World Health Organization (WHO) estimates that officially reported cholera cases only represent around 5-10 percent of actual cases worldwide. Many countries with the highest cholera rates are reluctant to conduct cholera surveillance or to officially report cholera cases or deaths. This is due to stigma associated with the disease and fears of trade sanctions and loss of tourism when cholera outbreaks are reported. When countries do acknowledge the existence of cholera, they usually under-report the number of cases, which can lead to insufficient allocation of resources to effectively deal with the disease.

The fight to prevent and control cholera has not benefited from recent increases in funding and interest within the global health arena. The lack of resources devoted to addressing the disease is staggering. In 2013, just $32.5 million or 0.2 percent of total overseas Development Assistance for Health (DAH) was earmarked to fight cholera. By contrast, in 2015, $10.8 billion or 29.7 percent of the $36.4 billion invested in DAH was devoted to fighting HIV/AIDS.

In October of 2010, a major cholera outbreak in the Caribbean nation of Haiti underscored the serious global health challenge that cholera presents. Just 10 months after a massive earthquake destroyed the Haitian public infrastructure and crippled its government institutions, an outbreak of cholera spread through all regions in the country. By the end of December 2010, Haiti reported more cholera cases than the rest of the world combined. As of August 2015, more than 9,000 Haitians had died as a result of the cholera outbreak and more than 700,000 people had been sickened.

The Opportunity

Within the cholera community, there was intense and sometimes contentious debate about the most effective approaches to prevent and control the disease. Public health and policy experts strongly believed that their respective approach was more effective. All approaches were significantly under-resourced. Advocates of detection, diagnosis, and treatment seemed at odds with WaSH advocates and those who advocated for the provision of oral cholera vaccines (OCVs). Each camp was concerned that additional resources devoted to one approach would divert resources from another approach. A neutral space where the expertise of all these groups and disciplines could be brought together was needed. The Task Force served as the perfect convening body and “gap-filler” given its credibility, resources, and expertise in mobilizing partnerships to solve global health problems.

Funded by the Bill & Melinda Gates Foundation in 2012, the Coalition was made up of approximately 130 members representing academic, research and medical institutions as well as governmental agencies, funders, local and international non-governmental organizations, vaccine manufacturers, and individuals.

The Strategy

Between 2012 and 2016, the Coalition endeavored to develop and implement a comprehensive strategy for cholera prevention and control that blended all the traditional approaches with the use of OCVs. OCVs proved to be safe and were administered to more than 4 million people in 14 countries, giving new hope to people affected by cholera.

As part of the Coalition’s comprehensive strategy, it planned and hosted four annual working meetings. These brought together researchers and public health professionals to jointly collaborate on solving the challenges facing the fight against cholera in a way that had not been done through other forums. The Coalition’s work meetings culminated in consensus statements that called on international and national institutions to bring to light the impact of cholera and promote the availability of effective interventions, including OCVs. One of the goals was to highlight for national political leaders that effective and comprehensive public health plans to prevent and control cholera could assist them in overcoming the stigma associated with cholera by showing that they were committed to addressing the issue rather than hide it.

Coalition members also emphasized the use of advocacy as an important tool against cholera and publicly called on development agencies to “increase their commitment to support the prevention and control of cholera.

In 2013, Coalition working groups published a Strategic Framework for Cholera Prevention and Control that brought together control and prevention guidelines based on existing research and identified areas for further research. The Framework flagged outdated recommendations and gaps in cholera prevention and control and encouraged development agencies to commit resources and attention to countries burdened by cholera.

The Impact

The Coalition served as a powerful vehicle for synergy and collective impact. The Consensus Statements issued following the first and fourth Coalition annual meetings were published in the widely circulated journal Vaccine, which increased the Coalition’s credibility and exposure with public health professionals not familiar with its work.

The Consensus Statements and Framework were important tools in the arsenal available to cholera-endemic countries. As a result of the annual meetings as well as the shared work in developing the “Strategic Framework,” many Coalition members from cholera-endemic countries began to collaborate, share information and ideas as well as use each other as resources rather than be solely dependent on foreign donors. For many of the participants at the Coalition annual meetings, it was the first time they had an opportunity to collaborate with each other, speak with one voice, and leverage the use of differing, sometimes competing, approaches to prevent and control cholera. Public health officials from cholera-endemic countries and U.S. researchers working on cholera interventions had opportunities to collaborate and share best practices – a major learning opportunity for all involved.

Another outcome of The Task Force’s work with the Coalition was the complete revitalization of the Global Task Force for Cholera Control (GTFCC). Prior to the revitalization process undertaken jointly by The Task Force and WHO, the GTFCC had become dormant and had little authority or influence. The GTFCC, which is based at WHO, now coordinates most of the cholera efforts at the agency, including providing links to additional WHO resources as well as other institutions. It also serves as an important coordinating body with worldwide reach with some Coalition participants serving as members and playing major roles in its work against cholera.

The Future

OCVs are crucial in mitigating the impact of cholera during humanitarian crises, but there are not sufficient quantities of the vaccine available to meet all global needs. Production capacity has been limited and the emergency stockpile is not yet adequate to fully meet the global need. In 2015, the Middle East refugee migration yielded several cholera outbreaks that resulted in some OCVs requests being turned down. The Global Alliance for Vaccines and Immunization (Gavi, the Vaccine Alliance), an international organization that promotes vaccination, has committed to support the increase in the OCV stockpile over a five-year period. The Coalition hopes to continue to engage WHO, Gavi, and OCV manufacturers Sanofi and Eubiologics to advocate for an increase in the production and availability of OCVs.

While more resources are being devoted to prevent and control cholera, these efforts are still stymied by a lack of sufficient funding and resources. Reducing cholera cases across the globe will require additional funding to increase the availability of OCVs and to ensure safe drinking water, proper disposal of human waste, and adequate hygiene.

The Task Force has exhausted its current support for the Coalition and is looking for new funding and partners. A solid foundation has been laid for future collaborative work in the fight against cholera – and the Coalition is well suited to address the challenges ahead and serve as an effective vehicle for advocacy and resource mobilization against the disease.

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