compounding emergencies

The cholera vaccine shortage could increase the toll of the earthquake in Syria and Turkey

A lack of financial incentive for pharma companies means many will die from a preventable disease

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An aerial view of the destruction caused by the earthquake in Turkey and Syria
Photo: Burak Kara (Getty Images)

The death toll of the earthquake that hit Syria and Turkey on Feb. 6 has topped 35,000, making it one of the most devastating catastrophes in recent times. According to the UN, that toll could end up doubling.

Further, beyond the direct casualties resulting from the earthquake, public health experts warn that another disaster might soon strike the affected area: cholera.


The foodborne and waterborne disease was already spreading in Syria before the earthquake, especially in the northwestern region of the country, where the ongoing civil war had damaged infrastructure and compromised access to clean water for at least 1.7 million displaced people.

As of mid-January 2023, there were 77,500 suspected cases of cholera in Syria, half of which were in the northwest. The earthquake damaged 37 health facilities in that region, forcing 20 to suspend operations.


In these conditions, cholera—which can be deadly, especially for children—can find fertile grounds to spread even further, potentially crossing the border into Turkey. The country has not recorded recent outbreaks of cholera, but the devastation caused by the earthquake would make it vulnerable to it.

To prevent this, first responders could start a vaccination campaign; cholera vaccines have existed for well over a century, after all. The problem: The world is facing several other cholera outbreaks—and a shortage of vaccines.

More cholera outbreaks and a depleting vaccine stockpile

Cholera, a bacterial disease transmitted primarily through contaminated water, is highly treatable and preventable. However, in the absence of treatment and access to clean water, it can quickly cause severe dehydration and death.


The disease spreads most quickly during natural calamities, such as wars, displacement, floods, earthquakes, or other situations where sanitation and healthcare infrastructures are compromised. Though it has been absent from most rich countries for many decades, it continues to kill around the world. In addition to Syria, outbreaks are ongoing in countries including Pakistan, Afghanistan, Malawi, Nigeria, Haiti. Between Dec. 20, 2022 and Jan. 15, 2023, nearly 75,000 cases of cholera have been reported worldwide.

This represents a dramatic global increase in outbreaks. In 2022 alone, according to the World Health Organization (WHO), 29 countries reported cases of cholera; in the five years prior, a total of 20 had. This trend might be here to stay, as cholera outbreaks are exacerbated by climate change.


Currently, the UN vaccine stockpile is insufficient to the point that the WHO has issued an emergency guidance limiting the immunization to one dose instead of the two required by the usual protocol.

At the end of 2022, the global supply of doses had all but ran out, and things aren’t likely to improve soon. Shantha Biotechnics, an Indian subsidiary of French pharmaceutical company Sanofi, which produces about 15% of the cholera vaccines, ended its supply contract and will stop delivering doses to the WHO stockpile by the end of the year.


How is it possible that the world is running short of a lifesaving vaccine that costs as little as $1.50 per dose? And what can be done to improve the situation?

Why we don’t we have enough cholera vaccines

The reason behind the shortage of cholera vaccines is quite straightforward. “Because it’s a disease of poverty,” says Nina Schwalbe, a professor at the Mailman School of Public Health at Columbia University. Cholera doesn’t affect wealthy nations, so pharmaceutical companies cannot charge high prices for them and generate massive profits.


The current global market for cholera vaccines is estimated to be around $95 million. This isn’t enough of an earning prospect to keep big pharmaceutical companies interested. Even if Sanofi absorbed the entirety of the market, for instance, the revenue would make up less than 0.2% of the drugmaker’s $47.8 billion total revenue for 2022. Smaller manufacturers such as South Korea’s EuBiologics, the maker of the cholera vaccine Euvichol, have more interest to stay in a market that is relatively large compared to their size, but are unable to meet global demand.

The global health community doesn’t have much of a leverage to force companies to produce more doses, either. As with other drugs, the initial research for most vaccines is funded by public money, yet there is no requirement for pharmaceutical companies to produce a drug that is necessary for the public good if they don’t deem it to be profitable—nor do they have to share the intellectual property if they no longer intend to produce it. Laws such the US National Defense Act can force companies to make products deemed essential to national safety, but have no international jurisdiction. Cholera vaccines—much like other drugs and treatments for conditions primarily affecting low-income populations—are overwhelmingly made outside the countries that need them.


Not enough cholera vaccines, and not good enough

This is not to mention the fact that, while a workable emergency solution, the cholera vaccines currently available need updating to be better fit to emergency delivery, says Schwalbe.


“We need to urgently invest both in the expansion of production of current cholera vaccines, but also in development of new cholera vaccines that can be delivered in crisis contexts,” says Schwalbe.

The current vaccines, for instance, are typically delivered orally in a two-dose protocol (although the UN is currently recommending one dose for most people, given the limited supply). This would be an issue even with better availability, as it requires reaching patients twice, ideally within six months, which can prove challenging in emergency settings.


Further, the vaccines are currently packaged in high-concentrations and delivered with a buffer. This again is impractical in emergency contexts where mobility might be limited. “It means you have to carry both the vaccine and the buffer, so it doubles the size of the fridge, and it doubles the size of the backpack that you have to carry with the vaccine in it,” says Schwalbe.

And, while cholera is most dangerous for children, the current vaccines can only be administered to those of at least one or two years of age, depending on the type. In order to protect infants, a vaccine should be developed that is included in the neonatal schedule in areas higher risk of cholera outbreaks.


These developments will require significant investments, to be sure. And, Schwalbe adds, “there is no market-driven reason to develop these vaccines.” The way cholera spreads makes it less of a potential threat to wealthy nations than other diseases, so it is ineffective to advocate for investments from the Global North with the argument that it’s good for their population safety, too.

Still, Schwalbe says there is a strong case for it. “Regardless of where you’re born and when,” she says, “the case is that it’s the right thing to do.”