The global health community is grappling with a resurgence of cholera, exacerbated by a critical shortage of vaccines. The World Health Organization (WHO) reported that the global stockpile of cholera vaccines was depleted from January to early March 2024 and again in October 2024. This shortage has coincided with a surge in cholera cases worldwide, which have increased by more than 50% compared to the previous year, reaching over 800,000 cases. The WHO has expressed "significant concerns" regarding how the vaccine shortage may impact national cholera prevention plans.
The shortage has forced health organizations to rely on a one-dose vaccination strategy, which experts warn may leave individuals vulnerable to reinfection. This strategy is particularly ineffective in children under five, further complicating efforts to control the disease. In Bangladesh, where cholera poses a significant threat, health officials estimate a requirement of around 100 million doses over the next four to five years to effectively implement preventative campaigns under their National Cholera Plans.
The depletion of vaccine stocks has prompted urgent calls for increased production. Bharat Biotech, an Indian pharmaceutical company, has highlighted a global deficit of approximately 40 million doses and aims to address this gap with its vaccine, Hillchol. Meanwhile, three new manufacturers are expected to begin vaccine production over the next six years, with Biological E entering the market in a few years and Biovac planning to start production by the end of 2028, targeting an annual output of 30,000 vaccines.
Struggles with Vaccine Production and Market Dynamics
The production and distribution of cholera vaccines are hindered by erratic demand and funding uncertainties. Manufacturers require assurance from Gavi, the Vaccine Alliance, that their products will be purchased before they can commence production expansion. This situation creates a precarious environment for manufacturers, as emphasized by Heather Sherwin, Director of Impact Investments at Elma Philanthropies:
“Without the proper funding in place, a manufacturer simply doesn’t have the funds to keep themselves going, or the price of their product becomes so high they will be outcompeted in the market.” – Heather Sherwin
Julia Lynch from the International Vaccine Institute (IVI) underscores the challenges associated with engaging companies in a market that may not be profitable:
“That's part of lowering the threshold for companies to get engaged in a market that's not going to be very profitable.” – Julia Lynch
The erratic demand for cholera vaccines complicates efforts to stabilize production and distribution. Daniela Garone of Médecins Sans Frontières highlights this issue:
“The demand is not stable — it’s erratic.” – Daniela Garone
Efforts to Boost Production and Supply
In response to the vaccine shortage, initiatives have been launched to enhance manufacturing capabilities, particularly in Africa. The African Vaccine Manufacturing Accelerator (AVMA), introduced in 2024, is designed to bolster manufacturing on the continent, focusing on diseases strategically important to Africa. Morena Makhoana, CEO of Biovac, emphasizes the necessity for local production:
“There has to be space for an African manufacturer.” – Morena Makhoana
The AVMA aims to increase cholera vaccine production in Africa, striving for self-sufficiency in vaccine manufacturing. Despite these efforts, the WHO acknowledges that current production levels are insufficient to meet growing global demand:
“Increased production has yet to meet growing global demand, as demand continues to exceed supply, which continues to hinder efforts to control cholera outbreaks and respond rapidly to the disease’s spread.” – WHO situation report
Bangladesh remains a focal point in the global fight against cholera. Firdausi Qadri from the International Centre for Diarrhoeal Disease Research in Dhaka stresses the urgency of addressing the vaccine shortage:
“It needs to be taken with more urgency.” – Firdausi Qadri
Strategic Shifts and Future Outlook
Given the limitations of the one-dose regimen, the WHO plans to transition back to its recommended two-dose regimen once sufficient vaccine supplies are available. This shift is crucial for ensuring long-term immunity and reducing vulnerability to reinfection. Firdausi Qadri reiterates the importance of a two-dose strategy for effective protection:
“You need at least two doses to protect them.” – Firdausi Qadri
As new manufacturers prepare to enter the market, there is optimism that increased production will eventually close the supply-demand gap. However, until these efforts materialize, concerns persist that the vaccine shortage could lead to a decline in vaccinations and potentially trigger a resurgence of cholera.
Daniela Garone articulates this dual challenge faced by healthcare providers:
“It’s a chicken-or-egg situation — you can prevent or you can treat.” – Daniela Garone
