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Promise Is Seen in an Inexpensive Cholera Vaccine Promise Is Seen in an Inexpensive Cholera Vaccine
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An inexpensive, little-known cholera vaccine appears to work so well that it can protect entire communities and perhaps head off explosive epidemics like the one that killed nearly 10,000 Haitians in 2010.An inexpensive, little-known cholera vaccine appears to work so well that it can protect entire communities and perhaps head off explosive epidemics like the one that killed nearly 10,000 Haitians in 2010.
A major study published on Wednesday in The Lancet found that the vaccine gave individuals more than 50 percent protection against cholera and reduced life-threatening episodes of the infection by about 40 percent in Bangladesh, where the disease has persisted for centuries.A major study published on Wednesday in The Lancet found that the vaccine gave individuals more than 50 percent protection against cholera and reduced life-threatening episodes of the infection by about 40 percent in Bangladesh, where the disease has persisted for centuries.
In a result that surprised researchers, the vaccine worked far better than supplying families with chlorine for their water and soap for hand-washing.In a result that surprised researchers, the vaccine worked far better than supplying families with chlorine for their water and soap for hand-washing.
The study is “really very important, and testing it in 270,000 people is phenomenal,” said Dr. Louise C. Ivers, a health policy adviser at Partners in Health, a medical charity that fights AIDS in Haiti and switched to treating cholera there after the earthquake.The study is “really very important, and testing it in 270,000 people is phenomenal,” said Dr. Louise C. Ivers, a health policy adviser at Partners in Health, a medical charity that fights AIDS in Haiti and switched to treating cholera there after the earthquake.
“In the last five years, the conversation has switched from ‘We shouldn’t use vaccine’ to ‘How can we use it best?’  ” “In the last five years, the conversation has switched from ‘We shouldn’t use vaccine’ to ‘How can we use it best?’ ”
Dr. Eric Mintz, a cholera expert at the Centers for Disease Control and Prevention, said the study “shows that the vaccine is feasible for government medical care.”Dr. Eric Mintz, a cholera expert at the Centers for Disease Control and Prevention, said the study “shows that the vaccine is feasible for government medical care.”
Cholera, which causes severe diarrhea, kills about 91,000 people a year, most of them children. It is endemic in over 50 countries, mostly in Asia and Africa.Cholera, which causes severe diarrhea, kills about 91,000 people a year, most of them children. It is endemic in over 50 countries, mostly in Asia and Africa.
When the infection unexpectedly spreads to a new country where no one has immunity — as it did after Haiti’s 2010 earthquake, and in Zimbabwe in 2008 — it can overwhelm health systems and kill thousands within months.When the infection unexpectedly spreads to a new country where no one has immunity — as it did after Haiti’s 2010 earthquake, and in Zimbabwe in 2008 — it can overwhelm health systems and kill thousands within months.
In Haiti, cholera is presumed to have been introduced by United Nations peacekeepers from Nepal; it sprang up near sewage leaks from their compound. The disease is widespread in Nepal. If the vaccine had been used as routinely there as it was in this study, experts said, the bacteria might never have reached the Caribbean and many lives would have been spared.In Haiti, cholera is presumed to have been introduced by United Nations peacekeepers from Nepal; it sprang up near sewage leaks from their compound. The disease is widespread in Nepal. If the vaccine had been used as routinely there as it was in this study, experts said, the bacteria might never have reached the Caribbean and many lives would have been spared.
In the 19th century, cholera was one of mankind’s great plagues. Repeated pandemic waves of Vibrio cholerae bacteria swept out of their home waters — the Ganges River delta — starting in 1817. Cholera infestation of urban rivers like the Hudson and the Thames led cities like New York and London to spend fortunes on networks of pipes to move clean drinking water from distant reservoirs and on deeper sewers to carry off bacteria-laden wastewater.In the 19th century, cholera was one of mankind’s great plagues. Repeated pandemic waves of Vibrio cholerae bacteria swept out of their home waters — the Ganges River delta — starting in 1817. Cholera infestation of urban rivers like the Hudson and the Thames led cities like New York and London to spend fortunes on networks of pipes to move clean drinking water from distant reservoirs and on deeper sewers to carry off bacteria-laden wastewater.
The surprisingly effective vaccine, called Shanchol, has been slow to gain acceptance.The surprisingly effective vaccine, called Shanchol, has been slow to gain acceptance.
It is based on a vaccine first made in Vietnam, then improved in the 1990s at the International Vaccine Institute in Seoul, South Korea, by a team led by Dr. John D. Clemens, an American scientist who now runs the International Center for Diarrheal Disease Research in Bangladesh. Shanchol has been made by Shantha Biotechnics in India since 2009.It is based on a vaccine first made in Vietnam, then improved in the 1990s at the International Vaccine Institute in Seoul, South Korea, by a team led by Dr. John D. Clemens, an American scientist who now runs the International Center for Diarrheal Disease Research in Bangladesh. Shanchol has been made by Shantha Biotechnics in India since 2009.
The vaccine’s protection lasts at least five years and perhaps longer, although that has not been proven yet.The vaccine’s protection lasts at least five years and perhaps longer, although that has not been proven yet.
It contains two killed disease-causing strains of cholera bacteria, is taken orally, and comes in a bottle about the size of a typical “energy shot.” The two-dose regimen costs $3.70. The Bill and Melinda Gates Foundation, which paid for much of the research, hopes to get the price below $2 as production increases.It contains two killed disease-causing strains of cholera bacteria, is taken orally, and comes in a bottle about the size of a typical “energy shot.” The two-dose regimen costs $3.70. The Bill and Melinda Gates Foundation, which paid for much of the research, hopes to get the price below $2 as production increases.
There were calls to use Shanchol as cholera overwhelmed Haiti in late 2010. But it had not yet been approved by the World Health Organization, a study done in Calcutta showing how well it worked was still unpublished, and few doses were available. Experts used to fighting cholera with clean water and safe toilets also feared the vaccine would consume too much scarce donor money.There were calls to use Shanchol as cholera overwhelmed Haiti in late 2010. But it had not yet been approved by the World Health Organization, a study done in Calcutta showing how well it worked was still unpublished, and few doses were available. Experts used to fighting cholera with clean water and safe toilets also feared the vaccine would consume too much scarce donor money.
“It was reminiscent of the early days of H.I.V., when some people favored prevention over treatment,” Dr. Ivers said.“It was reminiscent of the early days of H.I.V., when some people favored prevention over treatment,” Dr. Ivers said.
The Calcutta trial showing the vaccine gave individuals 65 percent protection against infection was finally published in 2011. The next year, Partners in Health tried it in a few Haitian villages where the epidemic still lingered and found about the same effectiveness. The Calcutta trial showing that the vaccine gave individuals 65 percent protection against infection was finally published in 2011. The next year, Partners in Health tried it in a few Haitian villages where the epidemic still lingered and found about the same effectiveness.
Doctors Without Borders used Shanchol in 2012 during a cholera outbreak in Guinea, in West Africa, where the vaccine seemed highly effective in the rural area where the outbreak started, Dr. Mintz of the C.D.C. said. But doses ran out after the disease reached the capital, Conakry. Ultimately, Doctors Without Borders concluded that the vaccine had given 86 percent protection in the early days. (Ebola did not hit Guinea until late 2013.)Doctors Without Borders used Shanchol in 2012 during a cholera outbreak in Guinea, in West Africa, where the vaccine seemed highly effective in the rural area where the outbreak started, Dr. Mintz of the C.D.C. said. But doses ran out after the disease reached the capital, Conakry. Ultimately, Doctors Without Borders concluded that the vaccine had given 86 percent protection in the early days. (Ebola did not hit Guinea until late 2013.)
After those successes, the W.H.O. began stockpiling Shanchol for emergencies, said Dr. Dominique Legros, an epidemiologist and cholera expert at the agency. The vaccine has since been used in outbreaks in South Sudan and Malawi.After those successes, the W.H.O. began stockpiling Shanchol for emergencies, said Dr. Dominique Legros, an epidemiologist and cholera expert at the agency. The vaccine has since been used in outbreaks in South Sudan and Malawi.
Ideally, he said, the stockpile would contain three million doses. Gavi, the vaccine alliance, has put it on the list of vaccines it buys for poor countries.Ideally, he said, the stockpile would contain three million doses. Gavi, the vaccine alliance, has put it on the list of vaccines it buys for poor countries.
The current study, conducted in the vast slums of Dhaka, the capital of Bangladesh, was the first effort to give Shanchol through a routine government health care to an urban population in constant danger of contracting the disease. It was a very large trial, with almost 270,000 participants broken into three groups. The current study, conducted in the vast slums of Dhaka, the capital of Bangladesh, was the first effort to give Shanchol through routine government health care to an urban population in constant danger of contracting the disease.
Shanchol provided 53 percent protection to individuals in the vaccine-only group and 58 percent in those that got it along with chlorine, soap and hand-washing advice. Although the level of protection is lower than in other studies of the vaccine, the population of the Dhaka slums is highly mobile, so only about two-thirds of any neighborhood where it was tested was reached, so the other third could keep spreading the illness or moving it into areas where it had been beaten, the authors said.Shanchol provided 53 percent protection to individuals in the vaccine-only group and 58 percent in those that got it along with chlorine, soap and hand-washing advice. Although the level of protection is lower than in other studies of the vaccine, the population of the Dhaka slums is highly mobile, so only about two-thirds of any neighborhood where it was tested was reached, so the other third could keep spreading the illness or moving it into areas where it had been beaten, the authors said.
There have been earlier cholera vaccines, but they had serious drawbacks. Injected vaccines developed decades ago gave only about 25 percent protection and did not enter the gut, where the bacteria attach, and so did not prevent transmission. These vaccines were considered irrelevant by the 1990s, although some countries still required them for entry. There have been earlier cholera vaccines, but they had serious drawbacks. Injected vaccines developed decades ago gave only about 25 percent protection and did not enter the gut, where the bacteria attach, so did not prevent transmission. These vaccines were considered irrelevant by the 1990s, although some countries still required them for entry.
Dukoral, an oral cholera vaccine made in Sweden since 2001, has been used by the W.H.O., but is expensive and must be taken with a large glass of buffer solution. Transporting tanks of buffer through narrow slum streets or into refugee camps is impractical, so Dukoral is useful mostly to wealthy travelers.Dukoral, an oral cholera vaccine made in Sweden since 2001, has been used by the W.H.O., but is expensive and must be taken with a large glass of buffer solution. Transporting tanks of buffer through narrow slum streets or into refugee camps is impractical, so Dukoral is useful mostly to wealthy travelers.
In a commentary published with the Lancet study, two epidemiologists from the London School of Hygiene and Tropical Medicine said Shanchol had “great potential for aiding disease control” but foresaw obstacles if dosing had to repeated every five years, so public health campaigns would be needed.In a commentary published with the Lancet study, two epidemiologists from the London School of Hygiene and Tropical Medicine said Shanchol had “great potential for aiding disease control” but foresaw obstacles if dosing had to repeated every five years, so public health campaigns would be needed.
Clean water and sewage control are still the ultimate weapons against cholera, they said.Clean water and sewage control are still the ultimate weapons against cholera, they said.