Why the Global Cholera Vaccine Shortage Goes Unnoticed Despite High Demand

With outbreaks in Haiti and beyond, PIH calls for increased production and distribution

Posted on Nov 29, 2022

A cholera vaccination campaign in Haiti, 2017
Dr. Myrtha Thermidor, deputy of the general vaccination program and supervisor of operations from Haiti’s Ministry of Health, administers the oral cholera vaccine to patients at an orphanage in Fond Michel during a 2017 immunization campaign. Photo by Cecille Joan Avila / PIH

Cholera outbreaks in Haiti and around the world are worsening, triggered by droughts, floods, war, and political instability that have forced vulnerable people to live amidst unsanitary conditions. At Zanmi Lasante (ZL), PIH’s sister organization in Haiti, doctors and medical staff are currently caring for more than 300 cholera patients at six clinics and hospitals in central Haiti; but more than 800 total have already been treated at ZL’s teaching hospital, Hôpital Universitaire de Mirebalais.  

The Haitian Ministry of Public Health and Population reported 11,953 suspected cases of cholera, 10,247 hospitalizations, and 227 fatalities as of November 28.

Children under 5 have been most affected; one reason is that malnutrition, which afflicts about 1 in 5 children in Haiti, makes young immune systems more vulnerable to disease. Cholera causes such severe vomiting and diarrhea that—if left untreated—a patient can die from dehydration within 24 hours.

Haitians never experienced cholera before 2010. That year, a new group of United Nations peacekeepers arrived in the country from Nepal, which had suffered a spike in cholera cases, and set up operations in a long-established base near Mirebalais with poor plumbing. Contaminated sewage leaked into the Artibonite River, a major water source for all Haitians, leading to a massive national cholera outbreak that lasted many years and killed more than 9,000.

PIH was among the first responders to that 2010 outbreak, ultimately treating more than 180,000 people in Haiti.  In 2012, PIH and its partners launched mass cholera vaccination campaigns in Haiti, reaching more than 45,000 people. That successful early effort led the World Health Organization to call for the establishment of a global stockpile of cholera vaccine. Additional mass vaccination campaigns, in 2016 and 2017, followed.

But the current surge in cholera globally has “so severely strained the supply of cholera vaccines that global health agencies are rationing doses,” according to The New York Times

We reached out to Garrett Wilkinson, PIH’s government relations and policy officer, who has been working on issues related to vaccine access for COVID, mpox (formerly monkeypox), cholera, and Ebola over the past few years, to better understand the status of the global cholera vaccine stockpile, why its supply is not meeting demand, who is most impacted, and what PIH is doing to make a difference.  

What is driving the current global shortage of cholera vaccines?

There’s limited funding to purchase cholera vaccines, and as a result there’s limited production. Most of the world's current cholera vaccine is manufactured by EuBiologics in South Korea. Around 15% of the world’s cholera vaccine is made by an Indian subsidiary of Sanofi (the company from which PIH directly purchased the original doses distributed in Haiti in 2012), but they’re leaving the market next year. EuBiologics is expanding manufacturing capacity and another manufacturer will be entering the market soon, but there will be a gap in availability of doses as these manufacturing shifts occur. 

Additionally, demand has grown with an increasing number of emergencies, such as the flooding crisis in Pakistan.  

Around 36 million doses are expected to be produced this year.

Wasn't the stockpile created to deal with such shortages? Why is it so depleted?

Like most global health programs, the size of the program is smaller than the burden of disease. We, as a global community, need to raise our aspirations, announce an intent to purchase millions more doses each year for the foreseeable future, and work with manufacturers to scale production to meet that demand. So, yes it’s about funding and supply and demand, but also a skewed global economy that doesn’t invest in preventing public health emergencies.

Who is most affected by the current vaccine shortage? Is the vaccine being rationed in countries experiencing cholera outbreaks?

Because cholera thrives in settings with limited clean water and sanitation infrastructure, those most impacted by the disease are the global poor and victims of natural disasters and war.

Right now, the cholera vaccine is being rationed to make up for supply constraints. It is usually given in a two-dose series, but as of mid-October, the International Coordinating Group (ICG), which was established in 1997 to coordinate the global distribution of vaccines to United Nations agencies including WHO, UNICEF, MSF, and the International Federation of Red Cross and Red Crescent Societies, have made the exceptional decision to recommend only administering one dose in order to stretch the limited supply.

One dose of the vaccine provides between six and 24 months of immunity, while the two-dose regimen delivered four weeks apart gives four years of protection. It’s urgently important that we scale production so we can maximize the benefit this vaccine can confer to people in need. 

What is PIH's involvement in this situation?

PIH has advocated for mass cholera vaccination campaigns for years, particularly in Haiti during times where other global health leaders disparaged cholera vaccination as not cost-effective. Because cholera can usually be treated with oral rehydration salts and antibiotics, some have argued that spending $1.50 per dose for millions of people is far more costly than merely treating the sick. This argument is misguided. First of all, people deserve not to be sickened with cholera in the first place. And secondly, vaccination can stop transmission and prevent an epidemic from spreading.

PIH is calling for increased cholera vaccine production. We’re speaking with our global partners about how we can raise sufficient funds to elicit increased production from existing or new manufacturers (this is sometimes called an Advance Market Commitment). The United States is a major investor in the United Nations system and ICG. U.S. global health funding is determined by Congress. Reaching out to your Congress member and raising this urgent concern to their attention can help.  

What is being done globally to fix this crisis?

Presently, this crisis is being addressed by dose rationing. This may be necessary to stretch limited supply in the short term, but it is an unacceptable strategy in the long term. While the primary cholera vaccine producer is increasing manufacturing, it’s not doing so by nearly enough. We need to see global partners step up with bold goals to administer millions more doses than we are now and to work with manufacturers to meet this demand.

The world has produced tens of billions of COVID-19 vaccine doses over the last two years. The technological challenge at hand with scaling cholera vaccine production is a mere fraction of what we just accomplished with COVID-19 vaccine production. We know it can be done. What is standing in our way is a lack of political will.

What about Haiti, specifically?

The Haitian Ministry of Public Health and Population and the prime minister have agreed to order cholera vaccine doses from the global stockpile. The total quantity of doses available and the arrival date in the country are still to be determined, but it could be in the next few weeks.

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