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Advancing Control of Cholera in the Interest of the Most Vulnerable in our Global Society

New approaches are needed to address the suffering and death caused by cholera. Having shaped populations for centuries, Vibrio cholerae is still responsible for completely preventable morbidity and mortality, the exact extent of which is not completely known. Estimated reports of cases are 2.9 million and 95 000 deaths per year, but these are considered to be underestimates [1]. A number of countries do not report cholera cases at all, even when the disease is confirmed to occur. The stigma of the disease for individuals, and of epidemics of the disease for countries, remains high, with fear of impacts on trade and tourism, and perhaps also political implications for those that have failed to prevent and adequately protect their constituents. Biologically, the risk of infection and disease with cholera varies based on an individual’s prior exposure and existing level of immunity, but social determinants are the primary influencers of illness and of death from cholera. Those without clean water, with lack of access to soap and sanitation, the displaced, the food insecure and the impoverished are most at risk of being infected, and when they become ill, are most likely to die. Cholera occurs when human feces have contaminated food or drinking water, and a lack of safe water is the biggest risk factor for outbreaks—a risk that is experienced by at least 2 billion people on the planet [2]. As a global community, we seem far too tolerant of the violation of the human right to clean water, essential as it is not just to preventing cholera but also to the control of other diarrheal diseases, essential for good nutrition and healthy growth, and critical for human dignity. Water insecurity places families in precarious situations, negatively influencing their choices and contributing substantially to ill health. In discussing Sustainable Development Goal 6—“Ensure access to water and sanitation for all”—United Nations literature states that “Clean water is a basic human need, and one that should be easily accessible to all” [3], yet despite the fact that it should be “easy,” we have not yet delivered. This is not really the result of technical challenges—though there are likely some. Rather, it is predominantly due to a lack of will to prioritize the issue and to invest the resources to get the job done. This is inexcusable. Meanwhile, as cholera cases continue to occur, we know what to do to save lives now, and there are opportunities to improve our surveillance, to reduce case-fatality rates, and to prevent transmission of cholera through individual-level and household-level interventions. In severe cases, as vomiting and profuse watery diarrhea ensue, the majority of deaths are related to hypovolemic shock. Prompt treatment with oral rehydration therapy (ORT) is lifesaving. ORT is simple, safe and inexpensive, and estimated to have saved millions of lives since its creation in the 1960s. Providing ORT, however, requires that a population at risk interacts with a health system in some way—even a system of modest quality can provide the necessities—through educated family members, equipped community health workers, or facility-based care. Some patients need other interventions as well, such as intravenous fluids, zinc, and antibiotics, though case-fatality rates from cholera are still far too high [4], a signal of the failure of health systems and a marker of the precarious situation in which many patients with cholera are living. A case-fatality rate <1% is often cited as a benchmark goal for outbreak response, but although that represents a substantial improvement from the preORT era, it shows to some degree how our expectations have stalled on what it is possible for us to achieve. Some institutions, for example, in Bangladesh [5] have shown far lower case-fatality rates, even in limited-resource situations. Finding and treating patients earlier and a better understanding of the care of special populations, including pregnant women, people living with human immunodeficiency virus, prison populations, and children with malnutrition, are key to reducing mortality rates further. So is investing in research on patient care; there has been some research, but not enough, on the care of particularly vulnerable groups, and even for some fundamental questions, such as the most appropriate use of antibiotics in treating cholera, we lack sufficient evidence to make definitive recommendations [6]. E D I T O R I A L C O M M E N T A R Y