As Malawi struggles with its biggest-ever cholera outbreak, its response is being hampered by the global shortage of vaccines, warned Dr Patrick Otim Ramadan, World Health Organization (WHO) Africa’s Incident Manager for Regional Cholera Response at a media briefing on Thursday.

By Wednesday, Malawi had recorded 40,284 cases and 1,316 deaths, with a case fatality rate of 3.3%, Dr Charles Mwansambo, Malawi’s Secretary for Health, told the WHO Africa media briefing.

Confirming that his country had run out of vaccines last month, Mwansambo said that while the vaccines were important in preventing transmission, cholera could only be stopped by addressing “water, sanitation and hygiene”.

“What is a bit unusual is that this cholera outbreak started during the dry season,” added Mwansambo. “Last year, we had tropical cyclones and floods that destroyed most of the water and sanitation facilities in the southern region, and this was the start of the current problem of cholera.

“We then had cases in the fishing community in the north, which is a very mobile population, and it has gone out of control. So there are a number of issues, starting with climate and the weather.”

Horn of Africa drought

Ten countries in the African region have reported cholera cases, with the DRC recording over 3,000 cases, mostly in the north of the country which has been destabilised by M23 insurgents. Many people displaced by the conflict between M23 and government forces are living in close quarters in camps with inadequate water and sanitation – a breeding ground for the rapidly spreading cholera bacteria that breed in dirty water, contaminated food and sewage.

#Africa 🌍 is witnessing an exponential rise in cholera cases amid a global surge. Cases recorded on the continent in January 2023 alone have already risen by more than 30% of the total caseload reached in the whole of 2022 👉🏿 https://t.co/HdzcBwMEPm pic.twitter.com/hPgszmmYSo

— WHO African Region (@WHOAFRO) February 9, 2023

DRC health official Dr Placide Welo Okitayemba said that most people in the camps got their water from water tankers, and many of the children in the camps are malnourished “and cholera progresses faster in children who are malnourished”.

“Some of the camps are in mountainous areas and it is hard to get water to them, so we may have to move some of the camps,” added Okitayemba, who directs the DRC’s cholera control programme.

The drought in the Horn of Africa is driving cholera cases in Kenya, Somalia and Ethiopia.

Case statistics for January alone accounted for 30% of the total cases in 2022, added Ramadan.

“We are concerned that, if this trend continues, we will far exceed the number of cases that we’ve seen in 2022 and it will put significant strain on the health systems in the countries that are affected, but also significant demand on the medical countermeasures that we need to respond to this,” he added.

Acute shortage of vaccines

With 18 countries globally reporting vaccines, there is an “acute shortage of oral cholera vaccines, routinely used to stop transmission in areas where access to safe water cannot be rapidly scaled up”, said Ramadan. 

To alleviate this shortage, the WHO recommended using a single dose of the two-dose vaccine last October, while at a global level, the WHO has been engaging with manufacturers.

As previously reported by Health Policy Watch, only two global suppliers make cholera vaccines available for mass vaccinations. Shanchol is produced by Shanta Biotechnics, a Sanofi subsidiary in India, and Euvichol-Plus, made by EuBiologics in South Korea.

Both companies supply the international cholera vaccine stockpile managed by the International Coordinating Group (ICG), a mechanism that coordinates the provision of emergency vaccines and antibiotics to countries during major outbreaks. 

All countries that need cholera vaccines apply to the ICG, and those that qualify for Gavi financing get free vaccines while the others need to reimburse the stockpile.

But Shanta Biotechnics announced a while back that it will stop making Shanchol this year, while production at EuBiologics is currently constrained as the company is expanding its facilities. The expansion will ultimately enable it to produce 50 million vaccines a year. 

Countries are also short of pre-packed cholera kits containing IV fluids and other measures to address infections, said Ramadan.

Lessons from COVID-19

Dr Theirno Baldé, WHO Africa’s incident manager for COVID-19, said all countries were better prepared to address pandemics, including cholera, since the start of the COVID-19 pandemic.

“It’s very important to mention that a lot of effort has been done by countries supported by WHO and also the partners to scaling up response capacities in the region, both for detecting new pathogens but also for trying to respond to them,” said Baldé. ‘But we are not there yet. We need to triple our response mechanisms.”

Mwansambo concurred, saying that Malawi is using the same structures that were put in place for COVID-19 to respond to cholera, with the Presidential Task Force coordinating the response and also a budget for pandemic preparedness and response. 

However, Ramadan stressed that, in the context of cholera, all countries also needed to urgently improve their water, sanitation and hygiene (WASH) plans.

Image Credits: L Pezzoli/ WHO.