Vaccines plus water, sanitation, and hygiene interventions in the fight against cholera – Authors' reply
Authors: Louise C Ivers
Journal: The Lancet Global Health (2017)

In their correspondence, Yael Velleman and Megan Wilson-Jones agree that controlling and preventing cholera requires a multidisciplinary approach including vaccination and safe water, sanitation, and hygiene (WASH) interventions. The affirmation that colleagues at a prominent organisation known for working to improve access to WASH—WaterAid—strongly agree with a combined, integrated approach to prevention and control of this disease is welcome. We also agree on how to leverage cholera vaccination campaigns into positive public-health opportunities. Our group found, for example, that in one cholera vaccination campaign in Haiti,1Aibana O Franke MF Teng JE Hilaire J Raymond M Ivers LC Cholera vaccination campaign contributes to improved knowledge regarding cholera and improved practice relevant to waterborne disease in rural haiti.PLoS Negl Trop Dis. 2013; 7: e2576Crossref PubMed Scopus (26) Google Scholar knowledge about WASH improved after vaccination against cholera, probably because the campaign was designed as part of a combined, integrated response. Velleman and Wilson-Jones state concern that my view is being propagated. However, their exact concern is not entirely clear, since we appear to agree on the merits of both combined approaches to disease-specific control of cholera and universal access to WASH as a basic principle of public health and as a human right. One interpretation of their concern as written might be that they do not believe a debate on the issue exists as I have described. If so, this disbelief might be because, although Velleman and Wilson-Jones have expansive global experience, they have not been involved in cholera control in Haiti in recent years, from whence my perspective arises. A debate between WASH and a combined approach to cholera control and prevention has been a prominent feature of cholera-related discussions in Haiti. However, studies such as the one by Azman and colleagues,2Azman AS Parker LA Rumunu J et al.Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study.Lancet Glob Health. 2016; 4: e856-e863Summary Full Text Full Text PDF PubMed Scopus (75) Google Scholar and others from Bangladesh, Haiti, South Sudan, and Guinea, as well as an increasing global experience in the use of oral cholera vaccines, have contributed in recent years both to the scientific understanding of the place of the oral cholera vaccine in cholera control and prevention and to informing WHO recommendations.3Abubakar A Azman AS Rumunu J et al.The first use of the global oral cholera vaccine emergency stockpile: lessons from South Sudan.PLoS Med. 2015; 12: e1001901Crossref PubMed Scopus (58) Google Scholar, 4Luquero FJ Grout L Ciglenecki I et al.Use of Vibrio cholerae vaccine in an outbreak in Guinea.N Engl J Med. 2014; 370: 2111-2120Crossref PubMed Scopus (119) Google Scholar Although the public stockpile of oral cholera vaccines is indeed limited in supply, one manufacturer recently announced their ability to produce up to 10 million doses of vaccine per year at low cost (US$1·75 per dose). Public-health debates in resource-limited settings are all too often focused on pitting one approach against another. For example, the history of epidemic infectious diseases is littered with examples of prevention pitted against treatment, from HIV infection to Ebola virus disease. These debates can be attributed to governments and implementing organisations being socialised for scarcity, compelled by long experience to ration the meagre resources at their disposal by arguing for one approach at the expense of the other, when the real problem is the need for more resources to ensure equitable access to basic human needs for the world's poor. The fact that 650 million people in the world do not have access to safe water means that we have much work to do to change the status quo. A cholera vaccine will never provide the broad social and health benefits of universal access to clean water.5Azman AS Ivers LC Legros D Luquero FJ Mintz ED Safe water, sanitation, hygiene, and a cholera vaccine.Lancet. 2016; 387: 28Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar However, in the short term, we must use all of the available tools, including vaccines, to protect lives from cholera, while accelerating progress towards the long-term goal of universal WASH. I declare no competing interests. Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort studyOne dose of Shanchol was effective in preventing medically attended cholera in this study. These results support the use of a single-dose strategy in outbreaks in similar epidemiological settings. Full-Text PDF Open AccessVaccines plus water, sanitation, and hygiene interventions in the fight against choleraThe Comment by Louise Ivers (November, 2016)1 references a supposed debate in cholera control between investing in universal access to water and sanitation and a multidisciplinary approach focused on cholera vaccination with specific evidence-based water, sanitation, and hygiene (WASH) interventions. Full-Text PDF Open Access