MSF/Mohamed Adan

Ethiopia: Amidst global cholera vaccine shortages, highly targeted interventions could prove an effective response

Sixteen countries around the world, including Ethiopia, have currently declared active cholera outbreaks.

With a massive global oral cholera vaccine shortage, equating to demand exceeding up to four times global production capacity for the past two years, there is an urgent need for affected countries to adapt their existing approaches for responding to outbreaks.

In collaboration with Ethiopia’s Ministry of Health (MoH), MSF is implementing an innovative strategy known as ‘CATI’ or Case Area Targeted Intervention to respond to a cholera outbreak in Jigjiga, the capital city of the Somali region. The ongoing outbreak was declared in October 2023, affecting people across the city and surrounding areas.

CATI is trialed for the first time in Ethiopia

“During cholera outbreaks, people who are living within a radius of 200 meters of an infected patient’s home are usually the people most at risk from becoming infected too, and the area could become a hot spot for transmission. This is why we are implementing CATI in collaboration with the Regional Health Bureau here in Somali region,” says Daniel Gudina, an MSF epidemiologist in Ethiopia.

MSF receives a list of the people diagnosed with cholera from the Regional Health Bureau (RHB) daily. After locating where the patient lives, the dedicated team will go there and spray disinfectant throughout the surrounding ten households closest to the patient’s home. People living in these ten households are also given a single dose of oral cholera vaccine and an antibiotic (Doxycycline), and are provided with hygiene kits. The hygiene kits include items such as jerry cans, water buckets, soap and water treatment chemicals. Additionally, the CATI team does health promotion about cholera and explains where people can access care if they fall sick.

Responding in this way is different to the traditional response approach for cholera outbreaks, which involves implementing interventions across a much larger geographical area, aiming to reach as much of the population as possible at a given time, and requiring significant resources.

As the Somali region is the second largest region in Ethiopia with vast plains bordering Somalia, Djibouti and Kenya, instead of implementing a broad and resource-heavy intervention, CATI relies on extensive surveillance and mapping of hotspot areas. Once a cholera case has been identified, CATI is implemented proactively in the early stages of an outbreak to prevent further spread of the disease. This is the first time this approach has been implemented in Ethiopia.

Members of MSF CATI team walking from house to house to respond to the cholera outbreak in Jigjiga, Ethiopia
Members of MSF CATI team walking from house to house to respond to the cholera outbreak in Jigjiga, Ethiopia
MSF/Mohamed Adan

In addition to rigorous case finding and health promotion activities with local health authorities, MSF supported the setup and running of a Cholera Treatment Centre (CTC) at Ayerdega Health Center to provide comprehensive treatment and care for patients with severe illness.

A Cholera Treatment Unit (CTU) was built at Jigjiga Primary Hospital to provide initial care and treatment for moderately ill patients, and five Oral Rehydration Points were also installed in various parts of the city. These rehydration points provide Oral Rehydration Solutions, which is a powder dissolved in water to treat patients with mild cholera and dehydration symptoms, improving patient access to care, and decreasing the number of patients arriving at the CTC and CTUs.

The CATI teams are formed by both MSF and MoH staff. A team includes staff dedicated to surveillance and data collection, nurses who administer vaccines, a water, sanitation and hygiene supervisor, health promoters, and staff responsible for infection prevention and control at the CTC, CTU and Oral Rehydration Points. A representative from the local neighbourhood administrative unit or kebele is also part of the team to support community engagement.

CATI approach shows promising results

“As we have limited resources to fight the outbreak, including the provision of mass vaccination campaigns due to the shortage of vaccines, the introduction of CATI symbolizes a turning point in the region's battle against cholera,” says Ermias Amare, public health emergency officer at Somali region’s Health Bureau (RHB) and CATI coordinator.

Between November 2023 and February 2024, MSF and the MoH treated more than 800 cholera patients, administered the limited number of oral cholera vaccines that were available to more than 8,000 people, and about 1,700 households have been provided with hygiene kits and health promotion information.

Despite CATI still being in a trial stage in Ethiopia and requiring further analysis of its ability to reduce illness and deaths among affected communities, initial results are promising.

According to the RHB, the number of confirmed cases has decreased in all districts except for one. The district where the number of patients is not decreasing is due to this area only having one water source, which is currently contaminated.

A member of the CATI team administers an oral cholera vaccine to a child in Jigjiga, Ethiopia
A member of the CATI team administers an oral cholera vaccine to a child in Jigjiga, Ethiopia
MSF/Mohamed Adan

Cholera can kill within hours, but it is preventable and treatable

Globally, 735,000 cases of cholera were reported last year, a 40 per cent increase in the number of reported cases in 2022. Deaths rose by 80 per cent in the same period.

In January 2024 alone, nearly 41,000 cases and 775 deaths have been reported globally.

In Ethiopia, the MoH reported a total of 36,061 cholera cases from 27 August 2022 to 26 February 2024, and 515 deaths. Among total cases, 4,870 are from 1 January to 26 February 2024. The Somali region is the region most affected.

Currently, all doses of the oral cholera vaccine in production until mid-March have already been allocated to affected countries, and demand for doses keeps growing, with current world reserves at zero.

MSF has been desperately raising the alarm about the grave consequences of this shortage in supply, calling on manufacturers to urgently produce more vaccines, and provide more technical support for new manufacturers to speed up regulatory processes to enable the drastic scale-up in production needed to save lives.

While vaccine supply remains dismally below what is required to protect the increasing number of people living in communities at risk of an outbreak, CATI is one of the response tools that could be used to mitigate the impact of this.

MSF has successfully implemented CATI in other cholera-endemic countries such as Haiti and Democratic Republic of Congo, effectively reducing the burden of the disease.

Now, in collaboration with Ethiopia’s MoH, MSF is compiling an impact analysis of this approach in Jigjiga, and anticipating further partnership with the MoH to assist at-risk communities in other parts of the country.

As of 15 February 2024, following confirmation of a person diagnosed with cholera, MSF expanded its response to Kebridehar, the second biggest city in Somali region. There is also a cholera response on-going in Lafaciise town, 40 km away from Jigjiga, and MSF is supporting with trainings on CATI implementation to RHB staff.

In the midst of a global cholera pandemic, that started in 1961 and has not yet ended, thousands of people remain at risk of illness and death from an entirely preventable disease.

Ethiopia can play a critical role in demonstrating to other countries how CATI can reduce the consequences of the shameful inaction we are witnessing by global vaccine manufacturers to scale up production.

MSF continues to call for accountability for the death of our colleagues.

On 24 June 2021, our colleagues María Hernández Matas, Tedros Gebremariam Gebremichael and Yohannes Halefom Reda were brutally and intentionally killed, while clearly identified as humanitarian workers, in Tigray. After extensive engagement with the Ethiopian authorities, we still do not have any credible answers regarding what happened to our colleagues. MSF will keep pursuing accountability for this incident, with the hope that this will help improve the safety of humanitarian workers in Ethiopia.