The Case Management Work Group of the Global Task Force for Cholera Control met for the third time in Veyrier du Lac, France, at the picturesque facilities of Les Pensieres, on 5th and 6th November, 2018, with the following stated objectives:

• Provide an update on the implementation of the Ending Cholera Roadmap and country engagement
• Provide an update on the GTFCC research agenda and priorities for the Case Management WG
• Present new training and case management tools and agree on a dissemination strategy
• Discuss a review of Rapid Response Teams during cholera outbreaks and lessons learnt
• Present an update on the treatment of cholera in patients with Severe Acute Malnutrition (SAM)
• Discuss opportunities for coordination with other GTFCC Working Groups, including areas requiring the development of technical guidance

Dominique Legros spoke about the update on the implementation of the Ending Cholera Roadmap in cholera endemic countries, and appreciated the changing policy environment around cholera. He specially highlighted two aspects:

• The exponential increase in the demand and use of OCVs globally, justifying the investment in the vaccine made by the Vaccine Alliance (GAVI), to enable its deployment in areas of need at low costs.
• The engagement of the political leaders and the positive political will in bringing out into the open the discussions about cholera, in a bid to end cholera once and for all.

The second achievement has been especially significant in light of the fact that conventionally,cholera has been viewed as an anathema. Often the outcome of poverty, poor access to safer water, sanitation and hygiene; and an issue inviting financial and political sanctions, cholera has remained under-reported and hidden away for fear of the repercussions. Therefore, active engagement from the political leadership of the cholera-affected countries is a major step in the right direction.

The partner updates were presented from: India (by me!), Haiti (Kenia Vissieres, Partners in Health), Nigeria (Seabstian Yennan, Nigeria CDC), UNHCR (Allen GK Maina), Alima (Eric Barte de Sante Faire), and Bangladesh (Azharul Khan, ICDDRB). All the presentations made at the meeting are available from the Fondation Merieux website.

Case Management challenges in healthcare facilities and at the community level were discussed at length. The model of the Malawi healthcare workers, which has also recently been discussed in an article in the BMJ Global Health, was presented. I had my reservations about the model, which had a lot of similarities with the ASHA worker model in India. I was concerned that as in India, too many responsibilities were being shouldered by the community level healthcare workers, and as a side effect, the quality of services provided by them could be compromised. The good thing was that there was a systematic training program planned for these workers. However, the quality control measures were not very clear to me.

In course of the second day’s discussions, the two groups which emerged as neglected groups, with little evidence base to guide clinical practice, particularly in difficult settings, like in the case of humanitarian crises, were pregnant women and children with severe acute malnutrition. Presentations from Medecins Sans Frontieres highlighted the plight of pregnant women, who were purging, and went into labor, in the cholera treatment centers. Thankfully, this is a small proportion of patients, but the clinical and humanitarian challenges in ensuring the dispensing of dignified care to these women is indeed a major challenge.

A presentation by the WHO Country Office representative from Yemen reiterated the scale of the cholera problem in the war torn country and the major hurdles in providing even basic healthcare. It was appreciable that even with such insurmountable challenges as were faced by the healthcare providers in Yemen, the reported mortality from cholera remained at less than 1%, around 0.3%. 

The meeting also dedicated some time to discuss and network between members (both present at the meeting and those that called in) in response to the call for proposals from Wellcome Trust-DFID, UK, for cholera control as part of the epidemic preparedness program.

Although significant achievements have been made in the past year, there still remain significant challenges to providing adequate, evidence based care to all, in difficult settings, particularly in cholera endemic areas experiencing war or political unrest or other humanitarian crises.