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Q&A with WHO: Cholera vaccine stockpile - a new tool to avoid needless suffering

Source: Thomson Reuters Foundation - Mon, 3 Mar 2014 11:20 GMT
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A displaced South Sudanese child receives an oral cholera vaccine in a camp for internally displaced people in Juba, Feb. 28, 2014. REUTERS/Andreea Campeanu
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BANGKOK (Thomson Reuters Foundation) - The World Health Organization (WHO) has activated for the first time a new cholera vaccine emergency stockpile to protect hundreds of thousands displaced by conflict in South Sudan and living in temporary camps.

Although there is currently no outbreak of cholera - an acute diarrhoeal infection caused by ingestion of contaminated food or water - the risk is high due to poor sanitary conditions and overcrowding, the WHO said.

With WHO coordinating the campaign, Médecins Sans Frontières (MSF) on Feb. 22 started vaccinations for 94,000 people in Minkaman camp in Awerial county, and the humanitarian organisation Medair was to vaccinate an additional 43,000 in camps in South Sudan’s capital, Juba.

Two oral doses of the cholera vaccine are required for an individual to be protected. The campaign begins with an initial round of vaccinations followed after a required 14-day interval by a second round. 

William Perea, the WHO’s coordinator for the control of epidemic diseases, spoke to Thomson Reuters Foundation by phone from Geneva about the emergency stockpile - which is managed by WHO, the International Federation of the Red Cross and Red Crescent Societies (IFRC), MSF and UNICEF - as a tool to fight cholera.

Q: What is the cholera vaccine and the emergency stockpile?

A: The cholera vaccine has been around for a while. The first once was licensed in 1991.

What we are trying to do with the emergency stockpile is say… let’s create a stockpile that will allow access to countries that would have the need to use the vaccine. We had to put some conditions and criteria around the stockpile, otherwise it's not manageable.

We have already more than 15 years of experience with emergency stockpiles of vaccines (for diseases) like meningitis and yellow fever. We used that experience that has proved effective to make vaccines available to countries that would not otherwise have access.

Q: Why is this vaccine not used more widely?

A: One of the main reasons for not using the vaccine is (some humanitarian aid sectors say) this vaccine will divert resources, and the problem with cholera is something that can be fixed with water and sanitation measures, and we shouldn't use money on vaccines to control disease.

We at WHO… think it's worth trying and seeing whether or not we can count on this tool and integrate it into a larger palate of control measures.

Q: When was the cholera stockpile set up?

We convened a meeting in 2012, and decided to establish this stockpile. By June, we were able to raise enough funds to establish a 2 million-dose stockpile. In July, we talked to manufacturers and started getting the vaccines around the last quarter of 2013.

We still don’t have the 2 million yet, because the manufacturers have not been able to produce the 2 million right away. We have around 1.5 million, and this is the first time we are using it.

Q: Where is the stockpile kept?

A: It’s kept at the manufacturing level (in India). We tried many things with (the vaccine stockpiles for) meningitis and yellow fever. We decided not to have a physical stockpile anywhere because of practical issues and issues with shelf life. We pre-pay for the vaccine, we set up procurement and logistics for transport and shipping in as short a time as possible.

Q: How much does this cost - both the vaccine as well as overall logistics?

A: The Shancol vaccine is around $1.80 a dose. Dukoral is a bit more expensive, around $4 to $5. Both vaccines are given in two-dose course.

The operational costs are related to shipping vaccines to the country, and making sure the vaccine is delivered to the people… between $1 to $2 additional per person, to make sure the vaccine is in the mouth of the people.

This is one of the things we need to document very well, but the experience we have is that operational cost really varies a lot. It can go from less than $1 up to $6.

Q: Where could the stockpile be useful?

A: The guideline for the vaccination is that it is for use in emergency situations, rather than prevention in cholera endemic populations.

However - again because this is the previous experience we have with yellow fever - if we know every year the vaccine has not been used for response to outbreaks because it was not requested or there was no need… our intention is to propose (the remaining vaccines) for preventive vaccination, to use them before expiration.

In WHO, we need to remind the world that for Latin America to control and eliminate cholera from the continent in the 1990s, we didn’t need the vaccine.

There are other things that can and should be done to control cholera, but… in situations where we know water and sanitation improvements will take longer and be difficult, (we can) try to use a tool that will help avoid needless suffering.

In camps in Iraq, or in Mexico where there have been outbreaks, they can control them without the vaccine because they have medical and WASH infrastructure and strong programmes that can deal with that without the use of the vaccine.

This is not the situation in South Sudan, where the WASH situation is so poor and healthcare limited - an outbreak would be catastrophic.

It’s not like yellow fever - if you don’t vaccinate, you don’t protect people, period. You have to vaccinate (with yellow fever), measles is the same. With cholera, it’s different.

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