Opinion: How do we turn the tide on this cholera pandemic?

While most people remain unaware, we are in the midst of a cholera pandemic that has ravaged lives since 1961. It’s the world’s seventh such pandemic, which began in Indonesia, spread to 45 countries, and now puts millions at risk every year. Among global development professionals, we know this killer well. But to the general public, cholera is often seen as a disease of the past — evoking images of Victorian London, dirty streets, and free-flowing sewage. In reality, cholera is a modern-day tragedy in regions with limited resources, and it demands our full attention. Cholera, an acute diarrheal infection caused by the bacterium Vibrio cholerae and spread through contaminated food and water, persists despite all we’ve learned about the importance of clean water and sanitation and the advancements we’ve made with highly effective vaccines. We can’t take our foot off the pedal of progress now. The World Health Organization recently reported a 13% increase in cholera cases in 2023 and a staggering 71% increase in deaths compared to the previous year. Cholera has spread to 45 countries, up from 35 in 2021, with major outbreaks in Afghanistan, Pakistan, Bangladesh, and across sub-Saharan Africa. There were over 535,000 reported cases and 4,000 deaths from a disease we know how to prevent and treat. With millions still at risk and outbreaks accelerating due to climate change and population displacement, we stand at a critical juncture. Surging cases and vaccine shortages over the past two years underscore the urgency. But amid this crisis, there is hope. Powerful tail winds are pushing us in the right direction as long as we act now to harness this momentum. The current vaccine landscape Until clean water and robust sanitation practices are universal, vaccines are the most effective tool to manage the epidemic and save lives. However, maintaining supply and ensuring equitable access remain significant challenges. WHO prequalified oral cholera vaccines in the 1990s, enabling procurement in low- and middle-income countries. In 2013, WHO introduced the first cholera vaccine stockpile to address global need. Then in 2014, the international public health and investment community rallied behind EuBiologics, a South Korean biotech company developing a new OCV for the public sector. This led to a dramatic increase in supply, from a few million doses to nearly 25 million in 2017. Fast forward to 2020, when Sanofi exited the OCV market, leaving EuBiologics as the sole manufacturer of a WHO-prequalified cholera vaccine. Global demand is approaching 100 million doses annually, double the current production capacity of EuBiologics. The path forward Despite challenges, recent advances in vaccine production — coupled with new partnerships — offer hope. To turn this momentum into sustainable solutions, we must focus on three areas now or pay the price later: diversity, innovation, and efficiency. 1. Diversity: Bring new suppliers online. Additional manufacturers will be needed to ensure secure supply moving forward. The good news is that efforts are already underway. Bharat Biotech in India has received OCV approval, and WHO should move swiftly toward prequalification for global procurement. Incepta in Bangladesh has a locally approved OCV, but regulatory delays have slowed global approval. Meanwhile, South Africa’s Biovac is preparing to start clinical trials, setting the stage for local production in Africa. Diversifying the supplier base reduces reliance on a single manufacturer and ensures greater availability of OCVs where they are needed most. 2. Innovation: Develop next-generation vaccines. Continuous improvements in existing vaccines and new technologies are essential to addressing the cholera crisis. EuBiologics, for example, has already increased production by simplifying its vaccine composition and investing in expanding manufacturing capacity. It’s worth noting Bharat Biotech’s latest approval is also for a simplified vaccine construct. Focusing on the most important serotypes — distinct variations of the cholera bacterium — to ensure broad protection and developing new approaches, such as a cholera conjugate vaccine for children under 5 years of age, will also be critical to long-term prevention. We must prioritize research into innovative vaccine technologies. 3. Creativity: Do more with what we have. As we work to expand production capacity, we must also maximize the efficiency of existing manufacturing operations. One near-term solution is to enhance the output of current production facilities by eliminating bottlenecks, particularly in the final steps of vaccine production, known as the fill-finish process. EuBiologics, for one, has partnered with GC Biopharma to streamline these operations. While water, sanitation, and hygiene programs may take years to implement fully, expanding vaccine production can address the crisis. A pivotal moment Consistent investment in vaccine manufacturing and procurement is vital to protecting vulnerable populations. While we have the tools to combat cholera, they will only be effective if manufacturers, donors, governments, and regulatory authorities collaborate quickly and decisively. By leveraging the momentum within the global health community, we can turn the tide on the cholera pandemic and protect millions of lives.