The Global Task Force on Cholera Control (GTFCC) to reduce mortality associated with cholera

History has been punctuated by major cholera pandemics. Genetic studies point to the Bay of Bengal being the source of these pandemics, meaning that they began in Asia. The seventh pandemic broke out in Indonesia in the 1960s. The GTFCC was formed to prevent and control the cholera epidemic when the fresh wave swept across Latin America in 1992. It is standard practice for the World Health Organisation (WHO) to bring together a group of experts to set the priorities and select the methods to be used to control a disease which is a major public health issue.

In 1998, cholera vanished from Latin America and was solely concentrated in Africa in the 2000s. The GTFCC sank into oblivion.

The Veolia Foundation started working on cholera prevention in Africa in the early 2000s. From 2000-2010, over 90% of cases occurred in Africa and four-fifths in the DRC (Democratic Republic of Congo). Experts did join forces to combat the disease but not at the global level.

The desire to revitalize the GTFCC arose as a result of the virulent epidemic in Haiti following the 2010 earthquake. The number of cases in the country was very high: 700,000 over the 2010-2013 period^[1].

• GTFCC members share a vision that collective action can stop cholera transmission and end cholera deaths.
• The GTFCC supports the deployment of multi-sector strategies to control the disease. This goal will be achieved through strengthened international collaboration and improved coordination amongst stakeholders involved in cholera control.
• GTFCC activities will aim to raise the visibility of cholera as a public health issue, facilitate sharing of best practice, and contribute to capability and resource development in all the at-risk areas.

The Task Force brings together operational and institutional stakeholders and researchers in all the cholera-related fields: surveillance and water access, treatment, hygiene, sanitation and vaccination to prevent and control the epidemic, and communication and advocacy to deliver effective messages.

Bringing together operational and institutional stakeholders and researchers is a unique feature of this type of group and fosters the cross-fertilisation of skills. Operational staff come up against concrete problems and need researchers to address them; the researchers work on research topics in conjunction with the operational staff, who in turn provide them with grassroots data: humanitarian workers and researchers work together, along with institutional stakeholders and funding bodies.

The GTFFC covers five areas:

• Epidemiology and surveillance: studying the spread of the disease, identifying and classifying its hotspots.
• Vaccination: OCV (Oral cholera vaccination)
• Medical care: treatment.
• The multi-factor WASH approach: Water, Sanitation and Hygiene.
• Fundraising and advocacy.

The work done by the different groups will enable the GTFCC to devise and promote a global cholera control programme taking the form of prevention initiatives put forward to governments.
The GTFCC’s organizational structure aims to be highly flexible. Each working group operates in its own way.
A meeting of all the members conducts a review of the work done every year. The 2015 meeting was held on 15-16 June in Geneva at the WHO’s headquarters. The various groups meet over the course of the months between these annual meetings. The three-year process of revitalizing the GTF began in June 2014.

The approach is based on studying the history and spread of the disease, in other words targeting interventions based on knowledge of the transmission dynamics. Europe was hard hit by cholera until the 19^th century. London was hit by an epidemic in 1854. Dr John Snow studied the disease’s spread across the city (the microorganism at the origin of the disease was not known at the time). John Snow concluded that the sick people had all used the public water pump on Broad Street in Soho and this proved to be the first insight into the causes of the epidemic. Sewers started to be built in London in 1858 and eliminated cholera from the capital. The WASH approach has therefore proved its long-term effectiveness in Europe and North America.

Epidemiology is the basis of the Veolia Foundation’s strategy in the country: analysing epidemic transmission dynamics enables us to combat them.^[1] We can pinpoint the locations to which cholera retracts (hotspots), even outside of epidemics, before spreading once again to other areas, by studying the history of the disease over 10-15 years. Hygiene and sanitation initiatives should target these hotspots to eradicate vectors of transmission. We firmly believe that the disease can be eradicated from these areas.
It should not be forgotten that cholera did not exist in Africa prior to 1970. The disease was imported from Asia. The DRC is the most severely affected country in the world. The first cases of cholera appeared in 1973 and are very well documented. The epidemiological studies have shown that three provinces are affected and this is where the heart of the epidemic is located: Nord Kivu, Sud Kivu and Katanga. Although cholera is persistent in several hotspots in Katanga, it is not actually widespread. People living on the shores of a lake in DRC are 7.5 times more likely to contract the disease. Ports, roads and stations are other aggravating factors. Kalemie is the world cholera capital because it combines all these aggravating factors, meaning that the risk of contamination is 25 times higher. The increasing amount of data available is helping to develop an archaeology of the disease. Kalemie in Katanga and Uvira in Sud Kiva are both located on the shoreline of Lake Tanganyika and are the main permanent disease foci. Outbreaks can occur in more remote areas. These are secondary non-persistent foci.

The Veolia Foundation works in both of these towns. The Foundation’s strategy is to understand the source of the disease in a given town. The solution may take the form of improved water access at some locations and sanitation in others. For example, a study carried out in Uvira showed the impact of piped water supply interruptions on the risk of cholera contamination.^[2] Having carried out an emergency programme (2010-2012) to provide an initial response to the situation, the Foundation has committed to a longer-term programme to deliver a lasting solution

In 2007, the Veolia Foundation supported the first strategic cholera eradication plan in DRC. The national guidelines highlighted seven source areas. The results achieved in DRC are the basis for the regional strategy rolled out throughout West Africa.

The track record and methodology developed in DRC are the reason for WHO selecting Dr Thierry Vandevelde, the Veolia Foundation’s executive director, to chair the Global Task Force. 

There are few fatalities if cholera patients are treated quickly, notably with oral rehydration solutions. Mortality has dropped to 1% thanks to the extreme emergency solutions applied as soon as an epidemic gets underway. However, in order to achieve this as has been done in DRC, the cost of epidemic preparedness is extremely high. Risky behaviours and environments for cholera are also the root cause of other diseases, including typhoid and diarrhoea; all water and hygiene-related diseases. Responses other than extreme emergency solutions do exist and need to be further developed. Long-term prevention can be achieved by focusing on water, hygiene and sanitation.

The GTFCC promotes a multi-sector approach to cholera in line with the World Health Assembly. The Assembly has deemed vaccination to be ‘complementary’ and states that it should not replace disease prevention based on access to drinking water, sanitation and hygiene. The WASH approach’s reach extends beyond the simple eradication of cholera: WASH helps to improve the living conditions of communities in locations where the effectiveness of vaccinations is limited.^[1]

The WASH approach covers water, sanitation and hygiene, as well as waste management and controlling vectors of cholera transmission.

The WHO asked Doctor Vandevelde to form the WASH group - 40 experts were selected for their recognized hygiene and sanitation skills.  The experts come from the major international organisations (such as UNICEF, WHO and the Red Cross), NGOs (including Médecins Sans Frontières and Action Against Hunger), universities, institutional stakeholders and private foundations.
The WASH group has selected four work areas and formed sub-groups to work on them:

• Strategic aspects: identify the distinctive characteristics of WASH interventions in different contexts such as emergency response, prevention or combined with a vaccination campaign, group leader: Didier Bompangue (University of Kinshasa, DRC).
• Economic aspects: develop an investment method for WASH interventions and apply it, leader: Dale Whittington (University of North Carolina, USA).
• Technical aspects: formulate recommendations on how to locally implement the WASH practices required to control cholera, leader: Daniele Lantagne (Tufts University, USA).
• Communication and funding: specify practical and budgetary aspects and convince people of the need for the WASH approach in high-risk areas, leader: John Oldfield (USA).

27 people attended the first meeting chaired by Thierry Vandevelde in New York on 4-5 May 2015. The sub-group experts selected their priority action areas and committed to a work schedule for the following 18 months. 20 topics were selected for the four sub-groups.

The 20 topics include:

• Strategic aspects: Produce an authoritative scientific publication explaining the WASH approach. The editorial team comprises five to six people representing the Strategy sub-group.
• Technical aspects: Household disinfection is a longstanding subject for humanitarian stakeholders involved in combating cholera. Standard practice has been to spray chlorine in the homes of people with cholera to prevent transmission. Since the cholera epidemic in Haiti, experts have felt that spraying is pointless but are divided on the issue of disinfection: does cleansing homes actually limit the spread of cholera? Researchers need to analyze the available data in order to provide a definitive response. Over the course of its initiatives, the Veolia Foundation collects a significant amount of data enabling researchers to study how cholera spreads in an urban area (data collected by GPS etc): the Big Data Era is here and represents a goldmine of information for researchers. A London School of Hygiene and Tropical Medicine student conducted a study of household disinfection from August to October 2015 and an operational research programme is currently being developed with UNICEF.
• Economic aspects: A cost-benefit and cost-effectiveness analysis of the different cholera control methods is a priority: WASH, vaccination and local medical treatment of cases. These three aspects are integrated on the ground, as well as vaccination. In DRC, an emergency call centre is set up when an epidemic is declared. The inhabitants contact the centre. The epidemiologist records the case. The epidemiologist then sends out a WASH team to find the patient and disinfect their home and potentially to implement measures in the neighbourhood. The patient is then given medical treatment at the health centre and information about the patient is sent back to the epidemiologist, who works out how the epidemic has spread so that prevention initiatives can be put in place. There is a need to compare the costs and contribution of each method used and those of an integrated approach.

The next meeting of the WASH group will be held in Africa in early 2016. The sub-groups may arrange their own meetings in between WASH group meetings.

11 of the 20 projects do not require funding, while the remaining nine do. The challenge at the present time is to raise funds for the nine projects.

The Veolia Foundation covered the cost of preparing for and facilitating the New York meeting and UNICEF provided the venue. The experts covered their own expenses and travel costs.

All the working groups met in Geneva on 15-16 June 2015. The meeting focused on four core topics:

• Deciding when and where cholera vaccination campaigns should be carried out.
• Addressing cholera detection equipment requirements on the ground.
• Creating a cholera glossary containing easily understood technical terms and devising procedures to define and describe cholera prevention methods.
• Finally, an advocacy topic: the need to incorporate the various cholera prevention approaches, such as patient support and vaccination, in order to build community resilience to the disease, and finally WASH procedures.

The GAAC (Global Alliance Against Cholera) was formed in 2010. It is not an operational agency but instead focuses on advocating the rollout of the WASH approach. Several GAAC members were invited to join the Global Task Force. GAAC and GTFCC seek to enrich each other.