Cholera deaths rose sharply last year, with multiple countries reporting deaths in the community, which highlight serious gaps in treatment, the World Health Organization (WHO) said today in an overview of activity in 2023.

Forty-five countries reported cases last year, one more than in 2022. Though cases were up 13%, deaths rose 71% compared to the previous year. More than 4,000 people died from their infections from a disease that is preventable and treatable, the WHO said.

Several factors have led to a bigger impact from cholera, including conflict, climate change, and inadequate safe water and sanitation. The WHO also noted a geographic shift from 2022 to 2023, with 32% less cases reported in the Middle East and Asia and a 125% increase in Africa.

Top hot spots last year included Afghanistan, the Democratic Republic of the Congo, Malawi, and Somalia.

Community deaths a new measure for cholera tracking

The WHO said many African countries reported a high proportion of community deaths, those that occurred outside hospitals, which is a new metric for monitoring the disease. In 5 of 13 reporting countries, more than a third of deaths occurred in the community.

Despite a shortage of oral cholera vaccine, a record 35 million doses were shipped last year, with a one-dose strategy to stretch supply still in place.

Early data from 2024 show that the number of cases reported at this point in the year is lower than 2023, with 22 countries reporting active cases. The WHO said the global risk from cholera is still very high.

A study of children who receive a tracheostomy and long-term home ventilation (HV) reveals that 75% get vaccinated against influenza, but of the 53% who complete their initial COVID-19 vaccine series, only 23% receive the recommended boosters.

A Boston Children's Hospital–led research team collected tracheal aspirates from 193 children on long-term HV and eligible for vaccination and conducted caregiver interviews to determine the cause of acute respiratory infections (ARIs) and to document flu and COVID-19 vaccination status from March 2022 to October 2023. 

The children were seen at 13 centers in 12 states and Washington, DC, participating in the Multicenter Tracheostomy Collaboration. The median patient age was 10.5 years, the median age at tracheostomy was 6.0 months, and 63% were boys.

The authors noted that children receiving HV are at high risk for ARI infection and death. The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend that all children aged 6 months and older receive annual flu and COVID-19 vaccines.

"Concern, however, exists that growing antivaccination sentiments, emerging 'medical freedom movements,' and specific mistrust of COVID-19 vaccines may negatively affect rates of vaccination among children at high risk," they wrote.

Discordance between access, uptake

"Compared with immunization status overall among US children aged younger than 18 years, our cohort had higher adherence to influenza vaccination (75% vs 50%), similar rates of initial COVID-19 vaccination (53% vs 50%), and much lower rates of receiving a COVID-19 booster (23% vs 50%)," the researchers wrote. 

Concern... exists that growing antivaccination sentiments, emerging 'medical freedom movements,' and specific mistrust of COVID-19 vaccines may negatively affect rates of vaccination among children at high risk.

Of participants given an annual flu vaccine, 61% also received a COVID vaccine. Among the 18% of patients never given a flu vaccine, 17% received a COVID vaccine.

A multivariable analysis showed that participants with a significantly higher likelihood of receiving a COVID vaccine were older (odds ratio [OR], 1.14) and previously vaccinated against the flu (OR, 8.93).

The authors said that families' engagement with the healthcare system suggests that they had access to screening, education, and vaccination, highlighting the need for qualitative studies on COVID vaccine resistance.