Date: Thu 26 Nov 2015
Source: WHO [edited]
WHO received notification from the National IHR Focal Point of Iraq of additional laboratory-confirmed cases of cholera. As of 22 Nov 2015, a total of 2810 laboratory-confirmed cases of _Vibrio cholerae_ O1 Inaba had been confirmed at the Central Public Health Laboratory in Baghdad, and only 2 deaths related to cholera were reported. These cases were reported from 17 Governorates of the country, namely Baghdad (940 cases), Babylon (675 cases), Qadisiyyah (442 cases), Muthanna (287 cases), Karbala (157 cases), Basra (102 cases), Wassit (68 cases), Najaf (46 cases), Thyqar (20 cases), Missan (21 cases), Dahuk (16 cases), Kirkuk (19 cases), Erbil (10 cases) Diyala (3 cases), Salaheddine (2 cases) Sulaimanneya (1 case) and Ninewa (1 case).
The Government of Iraq, with the support of WHO and UNICEF, completed the 1st round of the oral cholera vaccination campaign. The campaign, which ended on the 2nd week of November 2015, led to the vaccination of 229 000 refugees and internally displaced people (93 percent of the target population) across 62 camps in 13 Governorates. The turnout was very high. No refusals or concerns were raised regarding the vaccine. The 2nd round of vaccinations will begin in the 1st week of December 2015 to complete the recommended dosing regimen and maximize clinical protection in the target population. Oral cholera vaccination should be part of a comprehensive and integrated package that also includes clean water supply, improved sanitation and hygiene to provide the greatest chance of protection against cholera and other diarrheal diseases.
On 2 Dec 2015, the pilgrimage of Arbaeen is going to take place in Karbala. A total of 10 million pilgrims are expected to attend. The National IHR Focal Point of Bahrain, the Islamic Republic of Iran, Jordan, Kuwait, Oman, Qatar and the United Arab Emirates have put in place preparedness measures for the early detection and management of any imported cholera case from Iraq. The measures include activating the public health preparedness and response plan; enhancing disease surveillance at all points of entry and at all health care facilities; ensuring the availability of sufficient supplies and kits at laboratories; enhancing water surveillance for cholera; enhancing food inspection measures at points of entry; training health care workers in the assessment and management of cholera cases, enhancing strict compliance of infection prevention and control measures at all health facilities, particularly those designated to receive cholera suspected cases, and conducting activities to promote awareness of travellers to Iraq and the public about the disease.
Between 16 and 17 Oct 2015, the WHO Office for the Eastern Mediterranean held a sub-regional meeting for Iraq and its neighboring countries. Another regional consultative cholera meeting was held in Amman, Jordan from 17 to 19 Nov 2015, and all cholera endemic countries in the region as well as other stakeholders participated in the meeting. The meetings provided a set of recommendations for enhancing disease surveillance, including laboratory confirmation; case management and infection control; water sanitation and hygiene practice; capacities at points of entry; and risk communication.
WHO does not recommend any travel or trade restrictions on any country affected by cholera outbreak.
[The previous WHO Iraq report said that the total cases were 4858, which seems to be an error, given reports before and now after that one.
The use of a cholera vaccine during an ongoing outbreak was 1st demonstrated to be effective during an outbreak in the African country of Guinea in 2012 and reported in 2014:
The publication with its citation and abstract is:
"The use of vaccines to prevent and control cholera is currently under debate. Shanchol is 1 of the 2 oral cholera vaccines prequalified by the World Health Organization; however, its effectiveness under field conditions and the protection it confers in the 1st months after administration remain unknown. The main objective of this study was to estimate the short-term effectiveness of 2 doses of Shanchol used as a part of the integrated response to a cholera outbreak in Africa.
We conducted a matched case-control study in Guinea between 20 May 2012 and 19 Oct 2012. Suspected cholera cases were confirmed by means of a rapid test, and controls were selected among neighbors of the same age and sex as the case patients. The odds of vaccination were compared between case patients and controls in bivariate and adjusted conditional logistic-regression models. Vaccine effectiveness was calculated as (1-odds ratio) X 100.
Between 8 Jun 2012 and 19 Oct 2012, we enrolled 40 case patients and 160 controls in the study for the primary analysis. After adjustment for potentially confounding variables, vaccination with 2 complete doses was associated with significant protection against cholera (effectiveness, 86.6 percent; 95 percent confidence interval, 56.7 to 95.8; P=0.001).
In this study, Shanchol was effective when used in response to a cholera outbreak in Guinea. This study provides evidence supporting the addition of vaccination as part of the response to an outbreak. It also supports the ongoing efforts to establish a cholera vaccine stockpile for emergency use, which would enhance outbreak prevention and control strategies."
Although these are small numbers, the investigators working in way less than ideal condition should be lauded for this study, which may be the "straw that broke the camel's back" regarding using a cholera vaccine during an ongoing outbreak of _V. cholerae_.
The biologic used, Shanchol (produced in India), contains killed different biotypes of bacilli of both O1 and O139 serotypes. In a large study in Kolkata, India, a cluster-randomized, double-blinded, placebo-controlled study revealed a cumulative efficacy of the product at 5 years of 65 percent (95 percent CI [confidence interval] 52-74), with significant protection at the p less than 0.0001 level (1). The other WHO prequalified vaccine, Dukoral, produced in Sweden, contained several biotypes of O1 only together with recombinant cholera toxin B subunit.
As a review, the cholera toxin, encoded by the ctxA and ctxB genes, is the principal toxin produced by _V. cholerae_ O1 and O139 and is responsible for the disease. The genes are encoded with a filamentous bacteriophage. The toxin has many immunological properties that include impressive adjuvant properties and action as an anti-inflammatory agent. Each toxin molecule contains a catalytic A subunit (the active toxin) and 5 B subunits that bind the holotoxin to its ganglioside GM1 receptor. After internalization, a subunit of A, A1, will catalyze the ribosylation of a GTP-binding protein which increases the activation of adenyl cyclase and a chloride channel CFTR (cystic fibrosis transmembrane conductance regulator) which produces increased chloride secretion, intestinal water accumulation and diarrhea. It is mutations in CFTR that produces cystic fibrosis, a disease that affects a number of organs related to difficulties in fluid secretion (2).
2. Lutwick LI, Preis J: Cholera. In, Tropical Pediatrics: A Public Health Concern of International Proportions. NovaBiomedical, New York, 2014 (in press). - ProMed Mod.LL]
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