With Guinea facing its gravest cholera outbreak since 2007, some residents of the capital Conakry are clamouring to be vaccinated.
Conakry - where rubbish is piled high at every turn, many neighbourhoods flood regularly and just 2.2 percent of households are linked to a sewage system - has seen at least 3,630 cases of cholera this year, according to the World Health Organization (WHO), making it by far the hardest-hit area.
“We’re facing that pressure,” said Sakoba Keïta, head of disease prevention in the Guinean Health Ministry. “Some Conakry residents hear that their home communities have been spared thanks to the vaccine and they want protection too.”
The cholera vaccine has shown promising results in the handful of communities where it has been used: none of those vaccinated have been infected.
Protection from cholera is generally assured with proper hygiene, good sanitation and access to safe water; it is precisely because of Guinea’s lack of water and sanitation systems that the vaccine has an important role, health experts say.
As of 4 September 5,938 people across Guinea were reported infected with cholera - a bacterial illness that can kill within hours if untreated - with 111 deaths, according to the UN Office for the Coordination of Humanitarian Affairs (OCHA).
|Why not Sierra Leone?|
|There is no plan to use the cholera vaccine in Sierra Leone at this point, according to MSF communications officer Niklas Bergstrand. "Freetown [the capital] is such a big area - we'd have to vaccinate at least one million people which would be logistically very difficult,” he told IRIN.
“Generally if we do cholera vaccination it's in a more limited area such as a refugee camp, or in targeted zones as in the Guinea case. Vaccination in Sierra Leone would cost about 3.5 euros per person and we'd rather put our resources into treatment and other response efforts."
Neighbouring Sierra Leone is facing its worst cholera epidemic since 1995, with 15,834 cases, including 251 deaths as of 3 September, according to OCHA.
For now cholera vaccination is not generally done on a large scale. WHO and partner agencies are planning a cholera vaccine stockpile for epidemic control (see box) and looking at the possibility of introducing the two-dose oral vaccine into national immunization programmes in endemic areas.
Giving the vaccine early
Médecins Sans Frontières (MSF) and the Health Ministry vaccinated some 143,000 people in Boffa and Forecariah prefectures in April-May, early in the cholera outbreak.
MSF specifically wanted to test the effectiveness of giving the vaccine early in an epidemic, to see its potential in strengthening overall response, said Iza Ciglenecki, MSF project manager for diarrhoeal disease.
Photo: Nancy Palus/IRIN
|A man washes his hands during cholera prevention session in the Guinean capital Conakry. August 2012|
“The vaccine Shanchol was pre-qualified by WHO in late 2011; we were already working in Guinea and we had the opportunity to use it early in an outbreak,” she told IRIN. At about US$1.85 per dose Shanchol is cheaper than the other WHO-approved oral cholera vaccine, Dukoral.
MSF is studying the effectiveness of the campaign.
Guinean health official Keïta said he envisions that in future the vaccine will be part of the fight against cholera. “Because despite the lack of proper sanitation… and the lack of water in the zones initially affected here, the vaccine enabled us to stop cholera's spread.”
The UN Children’s Fund (UNICEF) in July issued guidance on the oral cholera vaccine, recommending “engagement with governments, WHO and partners to consider oral cholera vaccine use pre-emptively in endemic, at-risk and humanitarian settings and reactively in outbreaks.”
|Preparing for future epidemics|
|WHO is working with donors and other health agencies to create a stockpile of oral cholera vaccine (OCV) for use in epidemic control. The stockpile would be managed under the International Coordinating Group mechanism, as with the meningococcal and yellow fever vaccine stockpiles.
WHO says such stockpiles should not detract from other prevention efforts: detection, diagnosis, and treatment of cases with oral rehydration and antibiotics; establishment of a safe water supply; implementation of adequate waste disposal, sanitation, and hygiene; and communication and social mobilization.
The exact worldwide impact of cholera is unknown but it is estimated that there are 1.4 to 4.3 million cases a year, with 28,000 to 142,000 deaths.
Watsan also vital
Medical experts are quick to emphasize that the vaccine must not detract from other vital prevention measures like proper hygiene and water treatment - and adequate water and sanitation infrastructure in the longer term.
Keïta said vaccinations are always coupled with prevention education and the distribution of bleach. “The vaccine is to complement other measures. But it’s clear - in the areas where we vaccinated, the problem of drinking water access is still critical, the problem of sanitation is still critical. The bleach we gave out was enough to cover just one month. People are still living in pre-outbreak conditions and they've not been infected."
As of 2010, only 18 percent of Guinea's 10 million people used sanitation facilities considered adequate for avoiding contamination - 32 percent in urban areas, 11 percent in rural - according to the latest report by water/sanitation monitors at UNICEF and WHO. Some 74 percent of people used protected drinking water sources, though only 11 percent having piped water on their premises.
Water access varies widely by region. Cholera-infected communities in the Boffa and Boké regions live on islands where there is no drinking water supply, according to local health officials. Residents travel by boat or barge to mainland communities to fill up jerry cans.
Guinean health officials recently vaccinated some 7,500 people preparing to go on the Hajj pilgrimage. The Health Ministry is likely to use some of the remaining 48,000 doses in Boké and will later decide where to deploy the rest.