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Non-vaccine strategies for cholera prevention and control: India’s
preparedness for the global roadmap
Madhuchhanda Das
a
, Harpreet Singh
a
, C.P. Girish Kumar
b
, Denny John
c
, Samiran Panda
d
,
Sanjay M. Mehendale
a,
⇑
a
Indian Council of Medical Research, New Delhi, India
b
ICMR-National Institute of Epidemiology, Chennai, India
c
Campbell Collaboration, New Delhi, India
d
ICMR-National AIDS Research Institute, Pune, India
article info
Article history:
Available online 20 August 2019
Keywords:
Cholera
Prevention
Control
WASH
Disease model
abstract
Background: Recently World Health Organization’s Global Task Force on Cholera Control (GTFCC) has
published a global roadmap for prevention and control of cholera. We review preparedness of existing
governmental non-vaccine programs and strategies for cholera prevention and control in India. We also
describe strengths and gaps in the context of implementation of the global roadmap.
Methods: We reviewed published literature on non-vaccine based strategies for prevention and control of
cholera in India and analyzed strengths and weaknesses of Government of India’s major anti-cholera and
ante-diarrhea initiatives under Integrated Disease Surveillance Program (IDSP), National Rural Health
Mission (NRHM), and other disease surveillance platforms.
Results: The first strategy of the WHO global roadmap, namely, preparedness for early detection and out-
break containment, has been addressed by the IDSP. NRHM complements IDSP activities by focusing on
sanitation, hygiene, nutrition, and safe drinking water. We identified the need to adopt stricter case def-
initions and data validation protocols.
Multi-sectoral approach to prevent cholera occurrences and re-occurrences [the second suggested
strategy in the global roadmap], highlights identification of hotspots and implementing strategies based
on transmission dynamics. We recommend development of comprehensive models by integrating data
sources beyond the national programs to eliminate cholera hotspots in India.
Implementing the third proposed strategy in the global roadmap, coordinated technical support,
resource mobilization, and partnerships at local and global levels, has major challenges in India due to
structural issues related to health systems and health programs.
Conclusion: Even with a robust public health infrastructure, absence of a national cholera program might
have resulted in lack of specific focus and concerted efforts for cholera prevention and control in India. A
National Taskforce for Cholera Control must develop India-specific ‘National Cholera Prevention and
Response Road Map’ with an appropriate administrative and financially viable framework for its
implementation.
Ó2019 The Authors. Published by Elsevier Ltd. This is an open access article underthe CC BY license (http://
creativecommons.org/licenses/by/4.0/).
1. Introduction
Cholera has remained a public health problem in India for sev-
eral decades. However, there is no reliable nationwide data on its
prevalence [1]. Central Bureau of Health Intelligence (CBHI), and
Integrated Disease Surveillance Program (IDSP) of Government of
India publish reports on cholera incidence regularly. Cholera has
been reported from 21 states and Union territories of which 12
states are reported to be endemic for Cholera [2]. A study esti-
mated an annual incidence of 675,188 cholera cases and 20,356
deaths (2008–2012) in India [3]. Between 2014 and 2016, 197 cho-
lera outbreaks were reported in the country [3]. ‘National Health
Profile’ published by CBHI reported total 718 cholera cases and 3
deaths in 2016 while 913 cholera cases and 04 deaths were
reported in the previous year [4,5]. Provisional data for 2017
reported 494 cholera cases and 3 deaths [4]. In 2016, IDSP reported
114 cholera outbreaks in the country [6].
https://doi.org/10.1016/j.vaccine.2019.08.010
0264-410X/Ó2019 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
⇑
Corresponding author at: Indian Council of Medical Research, Post Box No.
4911, Ansari Nagar, New Delhi 110029, India.
E-mail address: sanjaymehendale.hq@icmr.gov.in (S.M. Mehendale).
Vaccine 38 (2020) A167–A174
Contents lists available at ScienceDirect
Vaccine
journal homepage: www.elsevier.com/locate/vaccine
Hence, there appears to be considerable discordance between
the cholera burden reported in published literature and data avail-
able with governmental systems and programs.
A recent watershed publication, ‘‘Ending Cholera—A Global
Roadmap to 2030”, by the Global Task Force on Cholera Control
(GTFCC) of World Health Organization (WHO) describes a vision
to reduce cholera-associated mortality by 90 percent by 2030 [7].
It highlights three strategies: (i) Early detection and quick response
to contain outbreaks, (ii) Targeted multi-sectoral approach to pre-
vent cholera recurrence in hotspots, and (iii) Coordinated technical
support, resource mobilization, and partnership at local and global
levels [7].
Prevention and treatment are the two critical components of
cholera control in any setting. Prevention encompasses use of Oral
Cholera Vaccines (OCVs) as well as non-vaccine interventions
focusing on Water, Sanitation and Hygiene (WASH). Both are com-
plementary and essential. However, despite in-country licensure,
OCVs are not yet adopted as part of the national immunization pro-
gram by the Government of India and strategies such as WASH,
early diagnosis, oral rehydration solution (ORS), and awareness
generation are emphasized. We present situation analysis in terms
of preparedness for prevention and control of cholera in India
focusing on non-vaccine strategies in the context of the GTFCC
roadmap. We have specifically examined the prevailing activities,
programs and the available infrastructure with a view to identify
future needs for cholera prevention and control in India.
2. Methods
The authors extensively deliberated and developed a matrix
defining the primary and secondary domains of prevention and
control of cholera in India. Electronic databases like NCBI-
PubMed, Cochrane, and CINAHL were searched using the keywords
‘‘cholera” and ‘‘prevention OR control” to identify all the published
literature including qualitative studies in India. We analyzed the
literature on non-vaccine prevention and control strategies for
cholera in the last 10 years. We also reviewed the strengths and
weaknesses of the major Government of India initiatives such as
IDSP, diarrhea control measures of the National Rural Health Mis-
sion (NRHM) and other disease surveillance platforms. A schematic
framework was developed to assess the level of preparedness for
cholera prevention and control in India within the bounds of
GTFCC roadmap.
3. Results and discussion
We developed a radial diagram showing WHO roadmap strate-
gies for control of cholera and then mapped our perceptions on
preparedness for cholera prevention and control in India in case
of various strategies, schemes and approaches as well as available
infrastructure to implement them. While doing this we have
retained alignment with the GTFCC for cholera prevention and con-
trol [Fig. 1a & b]. The colour codes and density reflect our percep-
tion and assessment of India’s level of preparedness after the
critical analysis. This schematic framework describes the existing
scenario and identifies future needs for cholera prevention and
control in India.
3.1. Early detection and outbreak containment
A robust outbreak control system could significantly reduce
mortality from cholera, particularly in countries with seasonal
recurrence of the disease [7]. Hence, the WHO roadmap lays
emphasis on containing outbreaks as soon as they are notified. Var-
ious components of an effective response include early case detec-
tion, quick response for containment, immediate community
engagement, early warning surveillance, readiness for supplies,
nation-wide network of laboratories and responsive health
systems.
3.1.1. Integrated surveillance system for early warning in India
An efficient surveillance system is critical in containment of any
diseases and for prioritization of areas for intervention. The
‘National Centre for Disease Control’ and NRHM functioning under
the ‘Ministry of Health and Family Welfare’ have created a mecha-
nism for early detection and early response to contain outbreaks in
India. The IDSP system connects villages to state-wide monitoring
systems through surveillance units. The Central Surveillance Unit
(CSU) is linked to the State Surveillance Units (SSU), and each
SSU is then connected to the District Surveillance Units (DSU). Each
DSU is linked to Peripheral Reporting Units (PRU) at the village
level. At present, 675 DSUs are operational across the country.
The IDSP network provides supervision and feedback from the
CSU to PRUs and ensures seamless data flow from PRUs to the
CSU for compilation and analysis.
The country-wide IDSP surveillance network has the potential
to detect emerging and re-emerging infectious diseases including
cholera in a timely manner. This network can also respond quickly
in post-disaster scenarios such as earthquakes, floods, and cyclones
and can initiate disease and outbreak surveillance immediately.
Information and communication technology has been made an
integral component of IDSP to enable networking, training, data
transfer, analysis and communication at districts, states and cen-
tral levels [8].
Since 2008, the IDSP portal has created a 24X7 call center facil-
ity to receive disease alerts from anywhere in the country on a toll-
free number. This facility is for reporting and verification of out-
break alerts, mitigating rumors, and initiating appropriate public
health actions.
The Indian Space Research Organization (ISRO) has set up a
satellite-based interactive network of 367 sites for training using
Education Satellite (EDUSAT) connectivity and presently covers
states like Maharashtra, Gujarat, Tamil Nadu, the North-Eastern
States, hilly states of Himachal Pradesh, Uttarakhand and Jammu
& Kashmir, and Islands [8]. Emulating ISRO, the ‘National Informat-
ics Centre’ has set up broadband-based connectivity at its 378 data
centers. These facilities can also be leveraged for efficient data cap-
ture and transmission to the IDSP CSU as alternative or additional
mechanisms. However, the call centers of IDSP and EDUSAT have
repeatedly experienced administrative and operational challenges
associated with the use of high-end technology. Their performance
has to become more dependable and consistent.
On a trial basis, less technology-intensive mechanism of short
messaging service (SMS) to capture data directly from the field
was made operational in 2008. However, it was observed that data
from the field was first being reviewed at the PHC level and filtered
data was being forwarded through the SMS. Although this was
done primarily to sanitize the content of information transmitted,
it was defeating the whole purpose of the instant SMS-alert system
to facilitate immediate response. The SMS-based data capture sys-
tem can be revitalized for wider, unfiltered data collection, rapid
confirmation and efficient linking with the IDSP system by imple-
menting validation and data authentication protocols [8].
3.1.2. Laboratory setup for detection of cholera in the Indian public
health system
Peripheral laboratories should rapidly confirm the diagnosis of
cholera and perform culture/ antibiotic susceptibility for confirmed
cholera cases. In the limited resource settings deploying trained
personnel for microbiological diagnosis of cholera in peripheral
health facilities is difficult. In such scenarios, rapid diagnostic tests
A168 M. Das et al. / Vaccine 38 (2020) A167–A174
(RDTs) can be a cheaper and a practical screening option in periph-
eral laboratories like primary health centers. Although not replace-
ments for stool culture or PCR, RDTs can be employed for initial
case detection and early warning of an impending cholera out-
break. Further case confirmation using classical microbiological
procedures or PCR can be done at secondary/ tertiary health
facilities.
Under IDSP, 117 District Public Health Laboratories (DPHL)
headed by trained microbiologists have been established in 29
states of India for providing diagnostic support during epidemic
situations. Additionally, 107 state-level referral laboratories (SRL)
have been established at select medical colleges/institutions in
24 states. Unlike DPHLs, SRLs have the capacity to perform tests
for culture, sensitivity and serotyping of cholera and other
entero-pathogens.
The CSU receives information on lab-confirmed outbreaks from
SSUs through e-mail, via e-portals, or by fax every week [8]. The
data generated by laboratory-network is used for detecting and
reporting cholera outbreaks in India. Between 1997 and 2006, a
total of 68 cholera outbreaks occurred in 18 states and union terri-
tories [3]. During 2004–2005, cholera was reported in 15 Indian
states, which included 7 outbreaks [9]. Between 2003 and 2012,
37,037 cholera cases were reported by the CBHI. During 2010–
2012, 185 cholera outbreaks were reported to the IDSP. Significant
improvements in the reporting of cases and outbreaks is an impor-
tant public health achievement in the country [9]. A more recent
analysis of IDSP data for the period 2013–2015 documented 179
outbreaks from different parts of India [10].
To summarize, a strong laboratory network of public health lab-
oratories has been created in India that sends reports to the CSU.
However, nearly 75% of the Indian districts are yet to be covered
under DPHL. There is a gross mismatch in the number of cases
reported by the IDSP network and DPHLs, as well as SRLs. Triangu-
lation of data from these sources for more effective mapping of
cholera in India is a major challenge. Initial cases of suspected cho-
lera are more likely to first seek medical attention at primary
health care facilities and hence they should be equipped with cho-
lera RDTs.
3.1.3. Rapid-response teams
Rapid response teams (RRTs) constitute a vital arm of IDSP as
part of preparedness for outbreaks and early response. A team of
an epidemiologist, microbiologist or laboratory specialist, and a
clinician is trained and deployed to investigate and respond to an
outbreak and report back to the national authorities immediately.
The RRTs are expected to initiate swift action to curtail further
spread of illness and prevent deaths by initiating emergency
response directed at WASH services, investigating risk sources
and working with affected communities to identify the urgent
interventions needed [8]. All diarrheal outbreaks reported to RRTs
are responded to. An analysis of acute diarrhoeal outbreaks in an
Indian state revealed a median time of 2.5 days to report to district
RRT (inter quartile range, 2–5 days) [11]. Delays in investigating
suspected cholera outbreak and delayed outbreak response have
been linked to high levels of morbidity and mortality.
Thus, the infrastructure and system for outbreak detection and
containment are in place in India. Additional work is required on
creating a critical mass of adequately trained skilled manpower
for RRT and their quick mobilization; improving IEC materials
and resources like drugs, vehicles, reagents etc.; and making the
technology more dependable for quick reporting and seamless
communication.
3.1.4. Preparedness and implementation of WASH
For many decades, developed countries in Europe and North
America have eliminated cholera by providing safe drinking water
Strongly prepared
Moderately prepared
Less prepared
Not discussed
Fig. 1. [A] Pictorial representation of the WHO Global Roadmap for Cholera Prevention and Control Strategies; [B] Pictorial representation of preparedness of India for
implementation of strategies for prevention and control of Cholera.
M. Das et al. / Vaccine 38 (2020) A167–A174 A169
and advanced sanitation systems. In 2015, improved sanitation
facilities were available for 44% of the population in India (65%
urban and 34% rural population) [12]. Improved drinking-water
sources were available for 88% of the Indian population. Despite
this the 2017 UN-Water Global Analysis and Assessment of Sanita-
tion and Drinking-Water report documented 71.7/100,000 diar-
rheal deaths in under 5 years due to inadequate WASH facilities;
a significant challenge for India to attain sustainable development
goals [13]. The allotment of the equivalent of USD 3.554 billion in
the 2017 budget outlay of the Government of India towards WASH
may not be adequate. Despite laws and policies on (i) urban/ rural
sanitation and drinking water supply, (ii) hygiene promotion, and
(iii) water resources planning and management at the national
level; India continues to have a significant burden of diarrheal dis-
eases [2,3]. The reasons for this need to be explored and well laid-
out schemes and outcome-oriented initiatives should be sup-
ported. Funding for public health emergencies, public health prac-
tices, and community-level behavioral change needs to be backed
by appropriate research evidence.
3.1.5. WASH - safe water supply
The ‘Ministry of Drinking Water and Sanitation’ oversees the
implementation of the ‘National Rural Drinking Water Program’
in the country. Rural drinking water has been included by the
Government of India in rural infrastructure development plan
called ‘‘Bharat Nirman”, which aims at providing adequate safe
drinking water of good quality to all so far uncovered habitations.
In 2014, the Prime Minister of India launched the ‘‘Swachh Bharat
Abhiyan”, a program to create awareness about sanitation by erad-
icating open defecation, preventing water contamination, and
improving public health. Swachh Bharat Mission portal suggests
that 27 out of India’s 36 states and Union territories are now open
-defecation- free with 98.6% of Indian households having access to
toilets [14]. The National Annual Rural Sanitation Survey of 2018–
19 has reported that the number of Indians defecating in the open
has reduced to less than 50 million from 550 million in 2014 [15].
However, all these schemes have operational challenges and
ground-level implementation problems and their benefits will be
realized in the years to come. Discussion on the issues of sanitation
and open defecation on open platforms is a significant
development.
3.1.6. Monitoring of water quality
‘‘Prevention and Control of Water Pollution Act” was enacted to
restore and maintain water bodies in India in 1974. The ‘Central
Pollution Control Board’ has established a network of monitoring
stations on rivers across the country and initiated monitoring of
water quality in 1977–78 under the Global Environmental Moni-
toring System (GEMS). The present network has 2500 monitoring
stations in 28 states and 6 Union Territories. It covers 445 rivers,
154 lakes, 12 tanks, 78 ponds, 41 creeks or seawater inlets, 25
canals, 45 drains, 10 water treatment plants (raw water), and
807 wells [13]. Monitoring of Indian National Aquatic Resources
System (MINARS), and the Yamuna Action Plan (YAP) are addi-
tional complementary networks and GEMS, MINARS and YAP
jointly constitute the inland water-quality monitoring network.
The groundwater quality monitoring network has been extended
to 807 locations in the country [16].
Water samples are analyzed for 9 core parameters, 19 general
parameters, as well as trace metals at selected locations. Appropri-
ate corrective measures are suggested for restoring the water qual-
ity of the polluted water bodies. Major water quality concerns
include ‘Total Coliform’ and ‘Fecal Coliform’ counts, high Biochem-
ical/ Biological Oxygen Demand (BOD) and salinity resulting from
organic matter and chemical pollution. Monitoring in 2011 indi-
cated that organic pollution was a predominant cause of pollution
of aquatic resources. It was observed that nearly 63%, 19%, and 18%
of water bodies had BODs of less than 3 mg/l, 3–6 mg/l, and above
6 mg/l respectively. Drinking water sources need to be protected
from organic matter and fecal contamination through very system-
atic efforts in India.
3.1.7. Community engagement for behavioral changes and hygiene
practices
NRHM of India has implemented ‘Total Sanitation Campaign’ in
350 districts of the country and has proposed to extend coverage to
the remaining districts [17]. It attempts to comprehensively deal
with sanitation and hygiene, nutrition, and safe drinking water
through its District Plan for Health. The Village Health and Sanita-
tion Committees (VHSNC), consisting of opinion leaders at the vil-
lage level, have been set up. ‘Accredited social health activists’ from
villages mobilize the community and facilitate people’s access to
health and health-related services by working closely with
VHSNCs. The activities of VHSNCs with reference to WASH include
(i) Monitoring and facilitating access to essential public services
such as clean drinking water and clean toilets, and (ii) Organizing
local collective action for health promotion through voluntarism,
community mobilization and sensitization against poor environ-
mental hygiene practices.
The Government of India has focused on creating awareness
about sanitation, safe water, and prevention of open defecation
but in order to radically improve environmental hygiene it is
important that practices and behavior are adopted at individual,
family, community, and national levels.
3.1.8. Preparedness of health care system and training of health
workers
Strengthening of the existing health care facilities, establish-
ment of dedicated facilities such as ‘Cholera Treatment Centers’/
‘Cholera Treatment Units’ as also the training of health workers
are critical elements in prevention and control of cholera. It is also
important to have trained and dedicated staff for outbreak investi-
gation and containment.
Though India has a robust public health infrastructure, training
of the healthcare staff in urban, rural and tribal areas in case detec-
tion and dehydration management is essential to reduce cholera
associated mortality. Ability to quickly mobilize RRTs and to man-
age uniform year-round availability of the adequate stock of drugs
and fluids at the most peripheral level are likely to significantly
reduce cholera-related morbidity and mortality.
3.1.9. Prepositioning stocks
Improvement of efficiency of a rapid response for cholera out-
breaks containment through pre-positioning of resources for diag-
nostics, patient care, and emergency WASH intervention is highly
recommended. Maintenance of sufficient stocks of WASH supplies,
namely, rapid microbial test kits, chlorine tests, water disinfection
technologies including chlorine, water tanks, supplies like hygiene
kits, ORS, gloves, culture media, soap, rapid diagnostic kits, chlo-
rine tablets, bleaching powder, etc. at healthcare facilities at all
levels is required for effective control of cholera outbreaks.
3.2. Multi-sectoral approach to prevent cholera occurrence and re-
occurrence
Outbreaks of cholera are often observed in vulnerable popula-
tions following disasters, conflicts and famines [18,19]. The Global
Roadmap emphasizes identification of hotspots (geographical
regions or communities heavily affected by cholera), identification
and mapping of vulnerable populations, and studying transmission
dynamics [7]. These activities require multi-sectoral coordination
A170 M. Das et al. / Vaccine 38 (2020) A167–A174
and have been employed successfully for the prevention and con-
trol of cholera world-wide [20,21].
3.2.1. Identification of hotspots
‘Hotspots’ are the areas of increased transmission potential.
Their identification plays an important role in research, policy for-
mation, and public health practice [22]. Appropriate interventions
and preparedness at the identified hotspots is the responsibility of
the government. The latest technological tools like geographic
information system, global positioning system and Google Earth
application programming interface along with mobile phones
[23], have been globally employed for efficient identification of
hotspots.
There are very few studies about cholera hotspot identification
in India. Based on spatial clustering reports of district level cholera
cases during 2010–2015 obtained from the IDSP, 13 out of 36
states in India were classified as endemic for cholera and 78 out
of the 641 districts in 15 states were identified as ‘‘hotspots”
[10]. On the other hand, 111 districts in 9 states were identified
as ‘‘hotspots” from a model-based prediction. The risk for cholera
in a district was negatively associated with the proportion of liter-
ate people, households using treated water sources and ownership
of mobile telephones. Conversely, areas with poor sanitation and
drainage conditions and lower levels of urbanization were associ-
ated with a higher cholera risk [10]. Surveillance data on cholera
outbreaks from 2000 to 2011 from the health department of the
Chennai Corporation and population data (2001) from census were
used to identify cholera hotspots in the metropolis [24]. There are
also many reports of isolated cholera outbreaks beyond the hot-
spots in India [25–27]. A map depicting cholera hotspots in India
has been published recently [1].
3.2.2. Risk and vulnerability assessment
Vulnerability for cholera is dependent on environmental, phe-
notypic and genotypic factors [28]. Several studies have identified
poor environmental conditions such as unclean water, unhygienic
environment, and poor waste management [29,30] to be strongly
associated with outbreaks and endemicity of cholera. Reported
phenotypic factors defining vulnerability include malnutrition,
homelessness, poor housing, and destitution; while nucleotide
polymorphisms and epigenetic modifications are its genetic deter-
minants [31].
Though there have been reports of cholera outbreaks in various
parts of India [9], group-specific risk and individual vulnerabilities
have not been adequately studied. Similar to studies of host geno-
types on predicting susceptibility to tuberculosis [32], studies can
be done in the context of cholera as well.
3.2.3. Modelling and transmission dynamics
Modelling and transmission dynamics are being used exten-
sively for understanding the pathogenesis and the spread of com-
municable diseases [33] and also for evaluating risk factors and
the impact of control measures [34,35]. Models vary from simple
deterministic equations to complex stochastic frameworks with
input parameters for immunology, clonality and the population
structure of cholera cases. Transmission dynamics models have
been developed for cholera world-wide for understanding the role
of climate on transmissibility of the disease [36–39]. Majority of
the studies have used susceptible-infected-recovered (SIR) com-
partmental models with different parameters. A SIR compartmen-
tal model with parameters to estimate the impact of clean water,
vaccination and enhanced antibiotic distribution programs has
been reported [40]. A SIR model parameterized with high asymp-
tomatic ratio and rapid waning immunity has been used for
explaining 50 years of mortality data from 26 districts in West
Bengal [41]. The hyper-infectivity of bacterial strains has been pro-
posed as a potential parameter for the impact of interventions on
the endemic cholera spread [42]. Recently, the weekly incidence
of suspected cases and fatality risk was used to parameterize the
family of logistic curves for describing the unbiased incidence in
the cholera outbreak in Yemen in 2017. Using logistics and gener-
alized logistics models, the cumulative incidence at the end of the
epidemic was estimated to be 790,778 (95% CI: 700,495, 914,442)
cases and 767,029 (95% CI: 690,877, 871,671) cases respectively
[38]. Mathematical models of cholera transmission have been pro-
posed with approaches for developing more detailed cholera out-
break models, including the addition of contaminated water
supplies, spatial effects, intra-household transmission, and inter-
ventions [43,44].
Models of cholera transmission need to be developed in India
and validated. Data from IDSP, state governments, and other data
sources needs to be integrated to develop a realistic predictive
model. Considering India’s population heterogeneity and strain
diversity, it is possible to develop a comprehensive SIR stochastic
framework model parameterized for several factors depicted in
Fig. 2. Though effective, some of the major challenges in developing
integrated models for cholera include limited capacity and inade-
quate trained manpower and non-uniform and non-validated data.
3.3. Coordinated technical support, resource mobilization and
partnership at local and global levels
The GTFCC created in 1992, has striven to be an effective and
well-coordinated platform for bringing together all multi-sector
technical partners from around the world to support countries in
their fight against cholera. The goal of the GTFCC is to support
national and inter-country capacities by providing a strong plat-
form for advocacy and communications, fund-raising, inter-
sectoral coordination, and technical assistance towards ending
cholera as a public health issue by 2030. Despite considerable
efforts, challenges such as a lack of acceptability of OCVs by policy/
decision-makers and integration with non-vaccine strategies such
as WASH need to be overcome. The Global Roadmap is an effort
to cover the last mile through support and cooperation from inter-
national and national-level stakeholders towards accelerating
action against cholera.
The comprehensive cholera control envisaged in the global
roadmap document requires significant financial investment by
the adopting countries. However, there is no mention of financial
assurance from the GTCC or WHO. Moreover, it is possible that
all countries may not have the technical skills, infrastructural back-
bone, and human/ financial resources to implement all the WHO-
recommended strategies. They are likely to face challenges in
designing appropriate strategies for their countries.
Various countries, including India, need to analyze their public
health scenarios to decide upon the most effective strategies that
require minimum financial commitment [Fig. 3].
It is important to establish an integrated surveillance network
with data from the IDSP, state-level surveillance units, and other
data sources to periodically estimate reliable prevalence estimates
of cholera in various districts, states, and regions of India. Strength-
ening of healthcare facilities with dedicated cholera units at all
levels, implementation of WASH, and community engagement to
encourage safe hygiene practices are the other critical strategies.
Establishing focused research priorities to foster multi-
disciplinary research on epidemiological, molecular, and clinical
aspects of cholera is essential. Establishing public-private partner-
ship ventures to stimulate the development of antimicrobials and
vaccines against cholera would also need coordinated action. India
requires a strong political commitment to eliminate cholera from
the country, as has been done for polio.
M. Das et al. / Vaccine 38 (2020) A167–A174 A171
For achieving the target of cholera control by 2030, what is
urgently needed is a national taskforce for cholera control with a
national cholera prevention and response road map for India.
Given the fact that health is a state-level subject when it comes
to legislation, a steering committee comprising top-level central
and state health ministry officials should be constituted, which
can be overseen by an oversight committee consisting of the Union
Health Minister and State Health Ministers. It is only with the
patronage of both central and state governments and ownership
of the program by all stakeholders at various levels within and out-
side the Indian health system that the target of cholera control can
be achieved.
It is a limitation of the present analysis that experts outside the
current group of authors were not involved in the situation analy-
Suscepble Infected Recovered
Resistant /
Protecon
Direct Contact
Indirect Contact
Genec resistance
Herd Immunity
Vaccinaon
Birth
Immigraon
Chemotherapy
Contaminaon
Bacterial growth/death
Cholera related
Comorbidity
Comorbidity
Reinfecon
Fig. 2. Comprehensive model for Cholera transmission dynamics.
Fig. 3. Organogram of structural framework of the cholera control programme in India.
A172 M. Das et al. / Vaccine 38 (2020) A167–A174
sis. Their inclusion could have provided additional insights in
understanding the Indian scenario with reference to preparedness
for cholera control.
4. Conclusions
India has a robust public health infrastructure. Programs like
IDSP, NRHM etc. provide comprehensive surveillance data on var-
ious diseases; however, they lack specific focus for individual dis-
ease prevention and control. Further, there is serious deficiency in
both horizontal and vertical linkage among various government
surveillance programs. India has in place a surveillance platform
and health system mechanisms for detection of ‘‘hotspots” as well
as proper implementation of vaccine/non-vaccine interventional
modalities. However, there also exist considerable gaps and/or
shortfalls in these systems that are compounded by inability to
prove cholera etiology in a time-efficient manner, often resulting
into under-reporting of the disease. An appropriate administrative
and financially viable framework for cholera control in the country
needs to be created. Addressing these inadequacies will be critical
for significantly reducing cholera burden in India and enabling
achievement of cholera control by 2030.
Authors’ contribution
All authors participated in the preparation of the article and
have approved the final version of the manuscript.
Disclaimer
The findings and conclusions in this paper are those of the
authors and do not necessarily represent the official position of
ICMR.
Declaration of Competing Interest
The authors have no conflict of interest to declare.
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
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Glossary
BOD: Biological Oxygen Demand
CBHI: Central Bureau of Health Intelligence
CSU: Central Surveillance Unit
DPHL: District Public Health Laboratories
DSU: District Surveillance Units
EDUSAT: Education Satellite
GEMS: Global Environmental Monitoring System
GTFCC: Global Task Force on Cholera Control
IDSP: Integrated Disease Surveillance Program
IDH: Infectious Diseases Hospital
ISRO: Indian Space Research Organization
MINARS: Monitoring of Indian National Aquatic Resources System
NRHM: National Rural Health Mission:
OCVs: Oral Cholera Vaccines
PRU: Peripheral Reporting Units
RRTs: Rapid Response Teams
SIR: Susceptible-Infected-Recovered
SMS: Short Message Service
SRL: State Based Referral Laboratory
SSU: State Surveillance Units
VHSNC: Village Health & Sanitation Committees
WASH: Water Sanitation and Hygiene
WHO: World Health Organization
YAP: Yamuna Action Plan
A174 M. Das et al. / Vaccine 38 (2020) A167–A174
