<< Back To Home

CSU 119/2010: THREE ON CHOLERA

Tuesday, 23rd of November 2010 Print

CSU 119/2010: THREE ON CHOLERA

Has the cost-effectiveness of oral cholera vaccinated been underestimated? So say Jeuland and colleagues.

The Mozambique article has been cited 20 times, but oral cholera vaccination has not yet caught on, as the recent experience of Pakistan and Haiti shows.

The reviews of Stories in the Time of Cholera are timely, covering as they do the societal response to cholera in countries of introduction.

Good reading.

BD

1)     COST-EFFECTIVENESS OF NEW-GENERATION ORAL CHOLERA VACCINES

Full text of the following abstract is at http://www.ncbi.nlm.nih.gov/pubmed/19824189

Jeuland, M., Cook, J., Poulos, C., Clemens, J., Whittington, D. and DOMI Cholera Economics Study Group (2009), Cost-Effectiveness of New-Generation Oral Cholera Vaccines: A Multisite Analysis. Value in Health, 12: 899–908.

Author Information

1.        1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA;

2.        2 University of Washington, Seattle, WA, USA;

3.        3 RTI International, Research Triangle Park, NC, USA;

4.        4 International Vaccine Institute, Seoul, Korea;

5.        5 Manchester Business School, Manchester, UK

*Correspondence: Marc Jeuland MSEE,

*Correspondence: Marc Jeuland, Department of Environmental Sciences and Engineering, CB #7431, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA. E-mail: jeuland@email.unc.edu

ABSTRACT

 

 Objectives: We evaluated the cost-effectiveness of a low-cost cholera vaccine licensed and used in Vietnam, using recently collected data from four developing countries where cholera is endemic. Our analysis incorporated new findings on vaccine herd protective effects.

 Methods: Using data from Matlab, Bangladesh, Kolkata, India, North Jakarta, Indonesia, and Beira, Mozambique, we calculated the net public cost per disability-adjusted life year avoided for three immunization strategies: 1) school-based vaccination of children 5 to 14 years of age; 2) school-based vaccination of school children plus use of the schools to vaccinate children aged 1 to 4 years; and 3) community-based vaccination of persons aged 1 year and older.

 Results: We determined cost-effectiveness when vaccine herd protection was or was not considered, and compared this with commonly accepted cutoffs of gross domestic product (GDP) per person to classify interventions as cost-effective or very-cost effective. Without including herd protective effects, deployment of this vaccine would be cost-effective only in school-based programs in Kolkata and Beira. In contrast, after considering vaccine herd protection, all three programs were judged very cost-effective in Kolkata and Beira. Because these cost-effectiveness calculations include herd protection, the results are dependent on assumed vaccination coverage rates.

 Conclusions: Ignoring the indirect effects of cholera vaccination has led to underestimation of the cost-effectiveness of vaccination programs with oral cholera vaccines. Once these effects are included, use of the oral killed whole cell vaccine in programs to control endemic cholera meets the per capita GDP criterion in several developing country settings.

2)      EFFECTIVENESS OF MASS ORAL CHOLERA VACCINATION IN BEIRA, MOZAMBIQUE

Full text, with figures, is at http://www.nejm.org/doi/full/10.1056/NEJMoa043323#t=article

Marcelino E.S. Lucas, M.Sc., Jacqueline L. Deen, M.D., M.Sc., Lorenz von Seidlein, M.D., Ph.D., Xuan-Yi Wang, M.D., Ph.D., Julia Ampuero, M.D., M.Sc., Mahesh Puri, M.S., Mohammad Ali, Ph.D., M. Ansaruzzaman, M.Sc., Juvenaldo Amos, M.D., M.P.H., Arminda Macuamule, M.S., Philippe Cavailler, M.D., M.Sc., Philippe J. Guerin, M.D., M.P.H., Claude Mahoudeau, Pierre Kahozi-Sangwa, M.D., M.P.H., Claire-Lise Chaignat, M.D., M.P.H., Avertino Barreto, M.D., M.P.H., Francisco F. Songane, M.D., M.P.H., M.Sc., and John D. Clemens, M.D.

N Engl J Med 2005; 352:757-767February 24, 2005

New-generation, orally administered cholera vaccines offer the promise of improved control of cholera in sub-Saharan Africa. However, the high prevalence of human immunodeficiency virus (HIV) infection in many cholera-affected African populations has raised doubts about the level of protection possible with vaccination. We evaluated a mass immunization program with recombinant cholera-toxin B subunit, killed whole-cell (rBS-WC) oral cholera vaccine in Beira, Mozambique, a city where the seroprevalence of HIV is 20 to 30 percent.

Methods

From December 2003 to January 2004, we undertook mass immunization of nonpregnant persons at least two years of age, using a two-dose regimen of rBS-WC vaccine in Esturro, Beira (population 21,818). We then assessed vaccine protection in a case–control study during an outbreak of El Tor Ogawa cholera in Beira between January and May 2004. To estimate the level of vaccine protection, antecedent rates of vaccination were compared between persons with culture-confirmed cholera severe enough to have prompted them to seek treatment and age- and sex-matched neighborhood controls without treated diarrhea.

Results

We assessed the effectiveness of the vaccine in 43 persons with cholera and 172 controls. Receipt of one or more doses of rBS-WC vaccine was associated with 78 percent protection (95 percent confidence interval, 39 to 92 percent; P=0.004). The vaccine was equally effective in children younger than five years of age and in older persons. A concurrently conducted case–control study designed to detect bias compared persons with treated, noncholeraic diarrhea and controls without diarrhea in the same population and found no protection associated with receipt of the rBS-WC vaccine.

Conclusions

The rBS-WC vaccine was highly effective against clinically significant cholera in an urban sub-Saharan African population with a high prevalence of HIV infection.

 

3)      BOOK REVIEWS, STORIES IN THE TIME OF CHOLERA

Editorial Reviews

From The New England Journal of Medicine

Stories in the Time of Cholera (not to be confused with the novel Love in the Time of Cholera, by Nobel laureate Gabriel Garcia Marquez) is a sociological analysis of a cholera outbreak in the delta region of the Orinoco River in eastern Venezuela in 1992 and 1993. One of the authors, Charles L. Briggs, Ph.D., trained in social anthropology and sociolinguistics and is professor of ethnic studies at the University of California, San Diego. He has worked in Venezuela since 1986 and is conversant in Warao, an indigenous language. He met his wife, coauthor Clara Mantini-Briggs, M.D., M.P.H., during the epidemic's early stages. Together they visited the delta, conducted interviews, evaluated health conditions, and collected graphic narratives (e.g., "We were shitting, the guy was shitting, shitting, shitting, shitting, and when he shitted again he passed out. `I'm going' -- those were his last words"), which provide the substance of this profusely footnoted, illustrated, and heavily referenced book. The authors' thrust is that "medical profiling" is both racist and "a prescription for institutional failure and human suffering." Having worked in cholera epidemics in the Philippines (1961), Calcutta, India (1962), Vietnam (1963), Thailand (1966), and Taiwan (1967), I am keenly aware of the difficulties in controlling outbreaks and delivering medical care when resources are limited or lacking. In fact, cholera occurs in epidemic proportions only under those conditions. The current great pandemic of cholera, widely regarded as the seventh, started in 1961 and entered the Western Hemisphere, for the first time in a century, by means of an explosive outbreak in Peru in January 1991. (Many of us had predicted earlier [Finkelstein RA. Cholera. CRC Crit Rev Microbiol 1973;2:553-623] that cholera would enter South America from Africa -- not from the west -- in the 1970s.) By year's end, Peru had reported more than 300,000 cases. The case fatality rate was less than 1 percent, owing to early and effective medical intervention. (Untreated, cholera may kill as many as 70 percent of people who have it, and the case fatality rate is many times higher in Africa.) Cholera then metastasized through South America and Central America, following routes of human transportation, and arrived in Venezuela, as reported in the book, in November 1991. It quickly reached the delta region of the Orinoco River, where it was encountered by Briggs, and where, he says, "nine of my closest friends had died. The survivors were terrified." It can now be stated categorically that deaths from cholera are due to failures in health care delivery. Why these failures occur is a major subject of the book. Treatment consists of vigorous replacement of the fluid and electrolytes that are lost in the voluminous cholera stools. Replacement can be performed either intravenously (when required) or orally (with solutions of oral rehydration salts [ORS] or their locally prepared equivalents). The "cholera cot" (a canvas cot with a hole cut in it and situated over a bucket) is a useful device to "keep score." The authors accuse public health officials of failing to inform and deliver health care to the indigenous population, or indigenas, as opposed to the upper-class, nonindigenous people, or criollos -- the "unsanitary" as opposed to the "sanitary" citizens. The authors regard this failure as a manifestation of racism, imply that it was intended to deflect the blame for the outbreaks from the institutions to the victims, and suggest that it contributed to the persistence of cholera in Venezuela. The indigenas were completely ignorant about cholera. They had no idea how to treat it (vernacular medicine [i.e., shamanism] was totally ineffective) or how to prevent it (they had no concept of the germ theory or of point-of-use water purification, which could have been decisive), and panic ensued. They descended on cities, where they were rejected or incarcerated. The authors claim that the victims were regarded as the cause of the outbreak by public health authorities and the press. The equation "barrio = poor = dirty = cholera" is, unfortunately, too true. Cholera has always been regarded as a social disease. It is vastly underreported. Countries do not like to report it because of its commercial impact -- they prefer to blame it on their neighbors -- and because of variations in the definition of a case. The authors recognize this problem but offer few helpful suggestions. Rather, they criticize administrators, health care deliverers, and epidemiologists, and they take a long time to do it. Richard A. Finkelstein, Ph.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.

Review

"This harrowing and beautifully written account chronicles a complex array of social responses to an epidemic and shows us what an engaged and responsible anthropology can offer those seeking to understand and prevent such plagues - and the injustices that foster them." - Paul Farmer, author of Pathologies of Power"

Product Description

Cholera, although it can kill an adult through dehydration in half a day, is easily treated. Yet in 1992-93, some five hundred people died from cholera in the Orinoco Delta of eastern Venezuela. In some communities, a third of the adults died in a single night, as anthropologist Charles Briggs and Clara Mantini-Briggs, a Venezuelan public health physician, reveal in their frontline report. Why, they ask in this moving and thought-provoking account, did so many die near the end of the twentieth century from a bacterial infection associated with the premodern past?
It was evident that the number of deaths resulted not only from inadequacies in medical services but also from the failure of public health officials to inform residents that cholera was likely to arrive. Less evident were the ways that scientists, officials, and politicians connected representations of infectious diseases with images of social inequality. In Venezuela, cholera was racialized as officials used anthropological notions of "culture" in deflecting blame away from their institutions and onto the victims themselves. The disease, the space of the Orinoco Delta, and the "indigenous ethnic group" who suffered cholera all came to seem somehow synonymous.
One of the major threats to people's health worldwide is this deadly cycle of passing the blame. Carefully documenting how stigma, stories, and statistics circulate across borders, this first-rate ethnography demonstrates that the process undermines all the efforts of physicians and public health officials and at the same time contributes catastrophically to epidemics not only of cholera but also of tuberculosis, malaria, AIDS, and other killers. The authors have harnessed their own outrage over what took place during the epidemic and its aftermath in order to make clear the political and human stakes involved in the circulation of narratives, resources, and germs.

From the Inside Flap

"Ten years ago, cholera 'raced' through part of eastern Venezuela, moving along social fault lines long in the making. This harrowing and beautifully written account chronicles a complex array of social responses to an epidemic and shows us what an engaged and responsible anthropology can offer those seeking to understand and prevent such plagues--and the injustices that foster them. Stories in the Time of Cholera is sure to have broad appeal within the social sciences and public health, and it should be required reading for public authorities and the press, whose prejudices clearly compounded the injuries meted out by the microbe itself. This is an exceedingly important book."--Paul Farmer, author of Infections and Inequalities

"Sometimes the historian can only envy the ethnographer's ability to observe and configure complex social and conceptual worlds. This study of cholera constitutes one of those occasions: I can only admire the authors' ability to unravel class, attitudinal, and institutional relationships, using social responses to cholera as their sampling device."--Charles E. Rosenberg, author of Explaining Epidemics

From the Back Cover

"Ten years ago, cholera 'raced' through part of eastern Venezuela, moving along social fault lines long in the making. This harrowing and beautifully written account chronicles a complex array of social responses to an epidemic and shows us what an engaged and responsible anthropology can offer those seeking to understand and prevent such plagues-and the injustices that foster them. Stories in the Time of Cholera is sure to have broad appeal within the social sciences and public health, and it should be required reading for public authorities and the press, whose prejudices clearly compounded the injuries meted out by the microbe itself. This is an exceedingly important book."-Paul Farmer, author of Infections and Inequalities "Sometimes the historian can only envy the ethnographer's ability to observe and configure complex social and conceptual worlds. This study of cholera constitutes one of those occasions: I can only admire the authors' ability to unravel class, attitudinal, and institutional relationships, using social responses to cholera as their sampling device."-Charles E. Rosenberg, author of Explaining Epidemics --This text refers to the Hardcover edition.

About the Author

Charles L. Briggs is the Alan Dundes Distinguished Professor and Professor and Professor of Anthropology at the University of California, Berkeley, and most recently coauthored Voices of Modernity (with Richard Bauman, 2003). Clara Mantini-Briggs, M.D. M.P.H., is an Associate Researcher in the Department of Demography and is affiliated with the PhD Program in Medical Anthropology at the University of California, Berkeley and the Director of Fundación para las Investigaciones Aplicadas Orinoco, which conducts research and initiates programs aimed at improving health conditions in Delta Amacuro, Venezuela.

--

To subscribe or unsubscribe from these Child Survival Updates, pls contact kidsurvival@gmail.com. If you unsubscribe, indicate from which E mail address you are receving these updates.

 

When subscribing, write from your most permanent E-mail address, not always that of your current employer.

 
Do not subscribe on behalf of friends or colleagues; forward updates to them for their decision.

Those wishing to read only malaria updates should subscribe at
kidsurvivalmalaria@gmail.com
 
Those wishing to read only vaccination updates should subscribe at kidsurvivalvaccination@gmail.com

 

24760492