No Short-Term Solution to Cholera Vaccine Shortage – But Preventive Vaccines May Stabilise Market
A Somali boy struggles to find water

The global cholera vaccines shortage relates to the unpredictability of the disease, and the fact that it unattractive to manufacturers as it is a disease of poverty – but if preventive vaccines are part of a routine vaccine package where cholera is endemic, this could stabilise demand and outbreaks

There is no short-term solution to the global cholera vaccine shortage as “the current manufacturers are producing to their maximum capacity, and one is increasing its production capacity but this increase is limited by technical constraints”, according to Dr Philippe Barbosa, the World Health Organization’s (WHO) technical lead on cholera.

Faced with at least 29 global cholera outbreaks – Haiti, Malawi and Syria battling particularly big outbreaks – and a diminishing supply of vaccines in the international stockpile, the WHO recently recommended that affected countries administer only one vaccine dose instead of the usual two. 

 Cholera is an acute diarrhoeal infection caused when people consume food or water contaminated with Vibrio cholera bacteria, and it usually affects those with inadequate access to clean water and proper sanitation.

As the disease primarily affects “the poorest and most vulnerable”, vaccine manufacturers have “no prospect of selling to rich countries”, so production is limited, Barbosa told Health Policy Watch.

“As the demand appears limited, this makes it unappealing for new manufacture to engage in this market,” said Barbosa, adding that the challenge of limited cholera data also made it difficult to forecast of future needs.

But Gavi, the global vaccine alliance, believes that it may be possible to stabilise vaccine production and supply by introducing preventative vaccines in cholera “hot spots”.

“We’re trying to get some preventive vaccination going in regions where cholera is endemic and that will help obviously to prevent outbreaks from a public health perspective,” says Gavi special adviser Aurelia Nguyen.

“It will also help with this ‘peaks and troughs’ view. As you can imagine from a manufacturing perspective, it is difficult to be able to just turn production on and off at very short notice,” added Nguyen, who has over a decade of experience in vaccine supply, most recently as managing director of COVAX, the international COVID-19 vaccine platform.

Gavi advisor Aurelia Nguyen

Only two suppliers

At present, only two 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. The ICG is made up of members from the WHO, UNICEF, Médecins Sans Frontières, and the International Federation of Red Cross and Red Crescent Societies.

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.

“What we’ve done with Gavi financing is show manufacturers that there is a certainty of regular funding for vaccines, and the minimum stockpile that we want to have at any point in time for outbreak is five million doses,” says Nguyen.

But Shanta Biotechnics announced a while back that it will stop making Shanchol next 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. 

Nguyen said that “production economics” were behind Shanta Biotechnics’ decision to quit the field, and Gavi has been working “very closely” with EuBiologics “and their volumes are going to keep increasing over the course of next year”.

Neither company responded to questions Health Policy Watch sent to them.

However, Gavi has also “been in very active discussions” with other manufacturers to enter the market in the next two to three year to ensure “resilience in the market”.

“We’ve been discussing with potential new entrants what it would take in terms of their developments, and it also links to another conversation in terms of regional manufacturing on the African continent,” said Nguyen.

Gavi has been in discussions with the African Union, and in the past week with the G7 and G20, about having “a stronger and more sustainable manufacturing base in Africa, and this is one of the vaccines that would be perhaps suitable for a new entrant coming from the continent”, she added.

Unpredictable demand

Typically, the international stockpile has about five to seven million vaccine doses which get replenished as it is used – but the unpredictability of outbreaks has made it hard to ensure regular supply.

“In 2020, we used five million doses for outbreak response. This year, so far we’ve already shipped 18 million doses and we have just seven million doses on hand at the moment and we plan to buy another five million through to the end of the year.”

However, what is more predictable is that climate change will drive more cholera outbreaks. The recent floods in 33 of Nigeria’s 36 states  – the worst in a decade – are expected to increase cholera cases, while Pakistan has been bracing itself for more cases after its recent devastating floods.

“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,” the WHO warns.

Meanwhile, earlier this week UNICEF described the cholera outbreaks in Syria and Lebanon as “alarming”.

“The acute epidemic in Syria has left over 20,000 suspected cases with acute watery diarrhoea and 75 cholera-associated deaths since its start. In Lebanon, confirmed cholera cases reached 448 in just two weeks, with 10 associated deaths,”  UNICEF warned in a media release.

“Malnourished children are more vulnerable to developing severe cholera disease, and the cholera outbreak is yet another blow to already overstretched health systems in the region.”

Image Credits: CNN, UNICEF.

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