**6. Prevention and control**

#### **6.1. Cholera prevention**

For the prevention and control of cholera, it is important to understand the factors that are responsible for initiating and sustaining cholera infection in a community [28]. Measures for the prevention of cholera include provision of clean water and proper sanitation to the choleraendemic communities.

#### *6.1.1. Health education*

Health education regarding personal hygiene and food hygiene should be provided to these communities. Media, community leaders, and religious leaders should participate in health education and social mobilization campaigns [29].

CDC has listed five basic cholera prevention messages. These include drinking and using safe water; washing hands with soap and water; using latrines or proper sanitation methods; proper cooking of food, covering it, and eating it hot; proper cleaning up of places used for bathing and washing clothes [30].

#### *6.1.2. Vaccines*

Currently, there are two oral cholera vaccines available: Dukoral and Shanchol. Dukoral is a killed whole cell vaccine including V. cholerae O1 serogroup and recombinant B subunit of cholera toxin. It can be given to children ≥2 years and to adults. For children 2–5 years of age, three doses, 1–6 weeks apart, are given orally, and booster dose is given after 6 months. For adults and children ≥6 years, 2 doses, 1–6 weeks apart, are given orally while booster dose is given after 2 years. The earliest onset of protection is 7 days after the second dose, and the protection at 6 months is 85–90% [31]. Shanchol is a killed bivalent (O1 and O139 serogroups) whole‐cell vaccine suspension. It can be given to ≥1 year of age; 2 doses, 2 weeks apart, are given orally. The earliest onset of protection is 7–10 days after the second dose, and there is 65% protection for at least 5 years [31].

In cholera-endemic regions and those at high risk for outbreaks, cholera vaccines should be used along with other prevention and control strategies. In these regions, high risk population may be targeted for vaccination. The high risk groups include preschool and school-aged children, pregnant women, and HIV-infected individuals [23].

#### **6.2. Cholera control**

Cholera-endemic areas should prioritize cholera control measures [23]. Countries facing complex emergencies and displacement of internally displaced people (IDP) on a large scale or refugees to places where the provision of safe water and proper sanitation is compromised, and they are vulnerable to cholera outbreaks. In such situations, it is critical to depend on surveillance data to watch for an outbreak and to implement appropriate intervention measures [32]. Thus, strengthening of surveillance system and early warning system is vital in places at high risk of cholera outbreak [29].

The main strategies for cholera control include appropriate and prompt management of cholera cases; strengthening laboratories; training and capacity building of health-care workers; and availability of adequate medical supplies for management [3, 29]. In addition, access to safe water, proper sanitation, appropriate waste management; personal hygiene and food hygiene practices; improved communication and public information are needed for the control of cholera outbreaks.

#### *6.2.1. Cholera vaccines*

Oral Cholera Vaccine should always be used as an additional public health tool in complex emergencies and should not replace usually recommended control measures such as improved water supplies, adequate sanitation, and health education. Once a cholera outbreak has started, the vaccine is not recommended as it takes time to provide protection and is also not costeffective [33]. Reyburn et al (2011) estimated that an organized mass vaccination campaign could prevent 34,900 (40%) cholera cases and 1695 deaths (40%) in Zimbabwe. However, the cost of the vaccines was an important barrier along with other logistic issues [34].

A well-organized, multisectoral approach is required to control cholera outbreaks. The effectiveness of public health interventions depends on an efficient surveillance system. There must be frequent and timely information-sharing at local as well as global level [11]. The administration of cholera vaccines may be considered for high risk population in high risk areas. Funds and resources should be provided to the deserving countries to improve cholera prevention and preparedness activities.

#### *6.2.2. International travel and trade*

Currently, there is no obligation of cholera vaccination for international travel. It is learned with experience that quarantine and restrictions on travel and trade are not very effective in controlling the spread of cholera. However, the travelers should be provided information regarding signs, symptoms, and prevention of cholera. The neighboring countries of choleraaffected areas should be advised to enhance their surveillance system for early detection and prompt response if any outbreak occurs [11].
