Cholera surveillance and estimation of burden of cholera.

Cholera continues to be poorly controlled in multiple epidemic and endemic areas across the globe, with estimated annual incidence of 1.3-4.0 million cases, resulting in 21,000 to 143,000 deaths worldwide in 2015. The usual approach for patient diagnosis and cholera surveillance is clinical examination of cases of acute watery diarrhea (AWD), confirmed by positive culture or polymerase chain reaction tests. Rapid diagnostic tests (RDTs) are used in regions with limited laboratory capacities but have been found to demonstrate large variations in performance, ranging in sensitivity from 58% to 100% and in specificity from 60% to 100%. Most countries rely on hospital-based surveillance of diarrheal disease to compute the cholera burden. The World Health Organization (WHO) recommends that countries assess public health events involving cholera against the International Health Regulations 2005 criteria and determine need for official notification using the standard case definition. Cholera is an often under-recognized and under reported problem because of differences in case definitions, reluctance by authorities to acknowledge and report cholera, inadequacies in hospital surveillance systems, lack of effective diagnostic tests and commonalities in clinical presentation of cholera with other AWD etiologies. The resulting gap in burden data impairs economic analysis of disease impact and identification of areas for targeted control interventions. There is an urgent need to strengthen surveillance data by supplementing reported numbers with estimates from literature reviews and data from modelling studies, developing better-performing RDTs, enhancing monitoring and evaluation processes of in-country surveillance systems, and encouraging countries to report cholera cases by "rewarding" better reporting with technical support and improved access to vaccines. It is imperative that immediate steps are taken towards strengthening surveillance and reporting systems globally, especially in cholera-prone and resource-limited areas, where it will enable countries to articulate their demand for resources more accurately.

Social mobilization for cholera prevention & control in India: Building on the existing framework.

Social mobilization is an important component of the delivery of vaccines and has to be carried out at different levels. It plays a very critical role in success of a campaign, as was shown by the Polio eradication program in India that was supported by SMNet, a platform created for the purpose. Learnings from this has been used for other vaccine deployments in India as well. In addition, there is a social mobilization effort for routine immunization. A guideline for social mobilization was created by UNICEF specifically for cholera vaccine use during Haiti epidemic in 2010. Since there is a need to develop a roadmap for cholera control in India, especially in the known hotspots, and after natural disasters, we suggest a possible strategy that could be built on the existing framework available in India.

Opportunities and challenges for cholera control in India.

The Indo Gangetic delta is homeland for cholera for almost two centuries now and there is evidence of global spread from this area. With migration of people to more urban areas within the country and increase in international travel, it is time for action against cholera in India, given its capacity to present itself in epidemic proportions. The Global roadmap to end cholera by 2030 was launched by the WHO Global Task force for Cholera Control which has led to renewed vigor and convergence of stakeholders across the world against the disease. There is also an emphasis on cleanliness and improved sanitation by the current government. The article discusses the unique opportunity for India in the current scenario, to act against diseases like cholera and challenges that are anticipated in deployment of interventions due to suboptimal surveillance and shortage of vaccines.

Molecular Adaptations and Antibiotic Resistance in Vibrio cholerae: A Communal Challenge.

Cholera, caused by the Gram-negative bacterium Vibrio cholerae, remains a major problem in developing countries. Although the disease can be managed by oral rehydration therapy, antibiotics are widely used nowadays to treat the disease. However, chemoprophylaxis has been proven to have no effect on the spread of the disease, but acts as a major driver for antimicrobial resistance (AMR). V. cholerae has evolved different ways to combat antibiotics used against them. This review comprehends the different molecular mechanisms of antibiotic resistance in V. cholerae, gaps in the development of new antibiotics, and the alternative strategies that can be used to treat the disease. The review advocates the use of antivirulence compounds rather than antibacterial compounds as a strategy to limit the increasing AMR. Also, the review expounds the role of community in preventing the diseases and tackling the global burden of AMR.

Typhoid fever: Control & challenges in India.

Enteric fever is a common but serious disease that affects mostly children and adolescents in the developing countries. Salmonella enterica serovar Typhi remains responsible for most of the disease episodes; however, S. Paratyphi A has also been reported as an emerging infectious agent of concern. The control measures for the disease must encompass early diagnosis, surveillance and vaccine to protect against the disease. Sanitation and hygiene play a major role in reducing the burden of enteric diseases as well. The current status of diagnostics, the surveillance practices in the recent past and the vaccine development efforts have been taken into account for suggesting effective prevention and control measures. However, the challenges in all these aspects persist and cause hindrance in the implementation of the available tools. Hence, an integrative approach and a comprehensive policy framework are required to be in place for the prevention, control and elimination of typhoid fevers.

Cholera prevention and control in Asian countries.

Cholera remains a major public health problem in many countries. Poor sanitation and inappropriate clean water supply, insufficient health literacy and community mobilization, absence of national plans and cross-border collaborations are major factors impeding optimal control of cholera in endemic countries. In March 2017, a group of experts from 10 Asian cholera-prone countries that belong to the Initiative against Diarrheal and Enteric Diseases in Africa and Asia (IDEA), together with representatives from the World Health Organization, the US National Institutes of Health, International Vaccine Institute, Agence de médecine préventive, NGOs (Save the Children) and UNICEF, met in Hanoi (Vietnam) to share progress in terms of prevention and control interventions on water, sanitation and hygiene (WASH), surveillance and oral cholera vaccine use. This paper reports on the country situation, gaps identified in terms of cholera prevention and control and strategic interventions to bridge these gaps.

Vaccine development and deployment: opportunities and challenges in India.

The Indian economy is among the fastest growing economies in the world. The country forayed into manufacturing vaccines starting with a few public-sector manufacturers in the late 1960s but has emerged as the major supplier of basic Expanded Programme on Immunization vaccines to the United Nations Children's Fund (UNICEF) because of substantial private-sector investment in the area. The Indian vaccine industry is now able to produce new and more complex vaccines such as the meningitis, Haemophilus influenzae type b, and pneumococcal conjugate vaccines, rotavirus vaccine and influenza A (H1N1) vaccines. This has been possible because of an attractive investment environment, effective and innovative governmental support, international partnerships and the growing in-country technical work force. A large number of vaccines, including those mentioned, is available and administered in the private sector within the country, but India has been slow in introducing new vaccines in its publically funded programs. Growth in the economy and technological accomplishments are not reflected in a reduction in health inequalities, and India continues to contribute significantly to global child mortality figures. This paper reviews the development of the Indian vaccine industry, policy support for it and its current status. It also highlights opportunities and challenges for the introduction of new and underutilized vaccines at home.