"Cholera is a neglected disease," says Dr. Dominique Legros, a medical epidemiologist for the World Health Organization.
"I was just at an international meeting about cholera and there were 25 people," Legros says, "a very low number for such a virulent infectious disease with such a huge burden globally."
"It only gets attention," he adds, "when there's a big outbreak."
Unfortunately, that is now the case.
In addition to an ongoing outbreak in Haiti that started after the 2010 earthquake, WHO is now responding to multiple outbreaks in the Eastern Mediterranean and East Africa. More than 10,700 cholera cases and 170 deaths have been reported in five countries in both regions.
Cholera is an infectious disease that causes severe watery diarrhea, which can lead to dehydration and even death if left untreated, sometimes within just a few hours of contracting the disease.
According to WHO, each year there are 1.4 million to 4.3 million cases of cholera and 28,000 to 142,000 deaths. Cholera rates tend to be reported in wide ranges because health authorities often report "severe watery diarrhea" instead of cholera. They don't always have the lab capacity to test for cholera. And governments may not seek to downplay cases to avoid any negative impact on trade and tourism.
Treatment, which includes rehydration fluids and antibiotics, is up to 80 percent effective when given soon after symptoms begin. Vaccines protect but can take up to four weeks to be fully effective. WHO and other agencies are on the ground in many of the affected countries, including Iraq, the Democratic Republic of Congo and Tanzania, and vaccine and treatment campaigns are underway where security and access allows.
People develop cholera by eating food or drinking water contaminated with a bacterium called Vibrio cholerae. In the Middle East, refugees fleeing the Syrian conflict often have little access to hygiene facilities and clean water. In East Africa, heavy rains and mudslides have carried the bacterium to remote regions and the situation could worsen because of ongoing El Nino conditions, which can lead to droughts and storms. Bacteria can become concentrated when there is little water and can spread via flowing water.
A WHO spokesman, Dr. William Augusta Perea Caro, also noted in a statement that "the deteriorating security situation in Iraq coupled with the disruption of public health services and increased population displacement makes the conditions favorable for transmitting the disease."
Goats and Soda spoke with Legros, who is part of WHO's cholera response team and has been on the ground in Iraq. The interview has been edited for length and clarity.
What needs to happen to control the outbreaks?
Interventions include treatment of cases, investigations in communities to find cases, provision of safe drinking water, disinfection of septic tanks to improve sanitation and better waste disposal.
In each country, WHO and its partners are supporting campaigns to encourage families to purify water, prepare food carefully and wash their hands.
Have you had vaccination campaigns?
WHO held a vaccination campaign from Oct. 31 to Nov. 1 in parts of Iraq. In clinical trials the vaccine is 85 percent effective but in real use it appears to be even more so because we see a protective effect from herd immunity. People who are vaccinated are less likely to pass [the disease] on to others, which helps protect even those who are not vaccinated.
How has the instability in the Middle East affected the outbreak?
In the Middle East, the outbreak started in early September and our most recent information is that it has been controlled in some areas. We are concerned because there are a lot of displaced people, and without safe water and good hygiene the cases can spread. We already have exportation of cases to Bahrain, Kuwait and Iran; our main concern is countries affected by the Syrian crisis. When security conditions are better, you can get in and vaccinate people. Last week the team was in Baghdad and earlier this week they were in Babylon. The situation changes every day and depends on getting a green light from U.N. security officers.
What about the situation in Africa?
Some areas are remote and hard to access. Dar as Salam in Tanzania is a big city with huge slums. The scale of the response needs to be built up with the government quickly before the floods start.
Are people in the regions receptive to vaccines and treatment?
In Africa in particular, people fear the disease, so when you come and say "I have a vaccine" it is very accepted by the population.
Do you have enough vaccine for everyone?
No. We have a stockpile of 2 million doses, about half a million have been used in Iraq. We select the areas and refugee camps where access to safe water and hygiene conditions is the worst. Also the vaccine is more effective preemptively than reactively because it takes weeks from vaccination to immunity. From the first case of cholera to being protected can take a month and in that month you can have a lot of illness and death among affected populations. Right now, in northern Iraq we are doing preemptive vaccination and have targeted refugee camps where wash conditions are the worst and where there are still few cases right now. In Tanzania, the outbreak started 2 1/2 months ago, so instead of vaccinating there, our priority is to find and treat patients and provide the population with safe water.
During a cholera outbreak in London in 1854, physician John Snow, believing that cholera was waterborne and not airborne, recommended removing the handle of a pump to a public well on Broad Street to stop the spread of the disease. Does that case hold lessons for today's outbreaks?
What we see now is that cholera occurs among the poorest of the poor because they have very limited access to safe water. You have to drink very bad water to get cholera, and if people drink from a contaminated water source, it means they have no alternative. The tendency is for authorities to close the contaminated well, but then where do people get their water? You don't want to remove the pump handle. You want to remove the bad water. And today that is feasible.
Cholera seems to take a backseat to diseases such as polio, malaria and TB, which more often make it into the headlines. Does that make it more challenging to combat?
We know how to control cholera. We have to speak for the people who have no voice and no access to clean water; they are the neglected ones.