Editorial: A small step for WHO, a big step for cholera control

Abstract

The WHO has issued a new set of recommendations for the control of cholera. And there, hidden in a forest of clauses of the kind more frequently seen in prenuptial agreements than in health recommendations, the careful reader will find the statement ‘... the use of OCV* in certain endemic situations should be recommended...’. Readers unfamiliar with the protracted battle over the use of vaccines for the control of cholera in endemic situations may read this sentence and miss a sea change. Cholera has a cachet in the lay world similar to tuberculosis or malaria. After all it is hard to imagine that Gabriel Garcia Marquez would have called his novel ‘love in a time of shigellosis’ or any other enteric disease; (Marquez 1988). There remains a justified horror of cholera outbreaks among people in less fortunate conditions. A cholera outbreak in Europe or the US is hard to imagine but so is a malaria outbreak. The reason why we do not have a world cholera day is probably because of the low mortality associated with cholera – if it is treated appropriately. A disease which can be cured within several days with rehydration and oral antibiotics does not register when we assess the impact in disability-adjusted life years (DALYs). And herein lies a major problem. DALYs were a major breakthrough. Bill Gates reportedly called the World Development Report 1993: Investing in Health (World Bank 1993), which brought the concept of DALYs to a wider public, a terrific read. Yet DALYs fail to capture the significance of a disease like cholera. Having lived through a single cholera outbreak is probably sufficient to fully understand the chain of catastrophic events: initially, curiosity about the first cases of watery diarrhoea admitted; the nosocomical infection of most or all patients on the ward; the closure of the ward; rigorous but belated disease-control measures; hospitals besieged by patients with watery diarrhoea; excess mortality not so much among the cholera patients but among other patients who cannot access the care they require. These are just the direct consequences. Family members have to look after their sick, shops and banks stay closed and the normal functions of a community come to a halt. At which stage the media catch on to the news and draw attention to the catastrophe affecting the community. In due time the government points out the damage caused by these unsubstantiated reports, and where an opposition exists the blame game can begin. This constitutes another unusual aspect of cholera. Not only can the damage not be assessed in DALYs, cholera remains a highly political issue. No matter where we met with affected communities, invariably the government was considered at least partially responsible and consequently highly sensitive. For example: Thailand does not report cholera cases. Public health experts are aware that ‘acute watery diarrhoea’ cases in Thailand are likely to be thinly disguised cholera cases. But before we single out Thailand, the fact that no cholera case has been reported from the People’s Republic of China has less to do with the absence of cholera than with the complete clampdown on reporting of cholera cases. Younger public health professionals early in their training become aware of the individual stigma associated with AIDS. Communities reporting cholera outbreaks are well aware of the stigma associated with cholera outbreaks. Besides the intangible damage cause by a tarnished reputation (who wants to live in a city thought to be cholera-ridden?) other negative effects should be measurable. The two economic sectors principally affected are seafood exports and tourism. While it is possible that Vibrio are inadvertently allowed to contaminate the water surrounding seafood during packaging, there is no evidence that Vibrio infect shrimp or fish. Yet the export market of small nations can collapse after reports of a cholera outbreak. Similarly, most tourists have no chance of experiencing a cholera episode as long as they follow the most basic rules of hygiene (only drink bottled or boiled water, only eat well-cooked food and fruit you have peeled yourself). It may therefore not come as a surprise that the countries currently reporting cholera outbreaks derive a larger income from humanitarian aid than from seafood exports and tourism: 94% of the 101 383 cholera cases and 99% of the 2345 related deaths registered with the WHO in 2004 occurred in sub-Saharan Africa (Sack et al. 2006). So what is a government official in charge of preventing the next cholera outbreak in her country supposed to do? If *Oral cholera vaccine. Tropical Medicine and International Health doi:10.1111/j.1365-3156.2006.01771.x