Polio Prevention and Eradication

 Polio prevention and eradication work is excellent all over the world.  

 

Global work toward polio eradication and transmission interruption is strong, though underappreciated [1]. Funding labor, supply and operations should be just as strong. Stating some of the obvious should help keep it simple.

• The primary evaluation of both funding and operations to prevent polio should be transmission prevention and eradication success. If we have not achieved our goal, we are not doing enough.
• The Global Alliance for Vaccines and Immunization (GAVI), the Global Polio Eradication Initiative (GPEI), Rotary and other organizations excel with philanthropic and nonprofit leadership [2,3,4,5,]. They should be supported [6,7].
• Polio is often cited as only endemic in Afghanistan and Pakistan. The World Health Organisation recently listed 7 countries infected with WPV1, cVDPV1 or cVDPV3 that have risk to international spread, 27 countries infected with cVDPV2, with or without evidence of local transmission, and other countries vulnerable to infection [8].
• The amount of dollars these agencies need to eradicate polio from the two remaining endemic countries, as well as tackle the infection transmission in the 30+ countries with known recent cases, should be clear. There should be consensus from all. Countries not needing outside support should also ask what can be done to help.
• The remaining gaps between inter-agency polio prevention workflows could be analyzed and addressed.
• A plan to prevent inactivated poliovirus (IPV) vaccine delays as countries switch from oral poliovirus (OPV) should be detailed. If IPV delays contributed to cVDPV2 or any oral poliovirus strain not covered in recent OPV, funding and global trade strategies should be improved.
• Long-term transition goals from OPV to IPV should be clear, and steps that industry can take to help the world achieve these goals should see industry commitment.  
• Labor could be outlined for increased funding, and labor could potentially be tied to integrated care.
• Primary care integration, pediatrician integration and other forms of vaccine integration should be designed for sustainability.
• Quality to vaccine administration could be continuously evaluated with standard metrics across all nonprofit donors and agencies.
• Military involvement in polio vaccination campaigns may or may not be quantified, and improvement to data could include this consideration.  
• Economic advisory should request consensus across global and nonprofit polio work, with the goal of long-term financing for polio eradication work.
• Geopolitical pressure could and should enforce anti-corruption and other barriers once vaccines are accessible to a country. 

The United States has achieved sustained success with polio prevention and eradication. The US can further these efforts.

• IPV and polio vaccine coverage data aggregation could improve, perhaps with improved technology. The CDC citation from 2016 [9] may no longer reliable for polio coverage rates in the US, and these citations are frequently the source for media [10].
• Pediatric vaccination coordination between public health and primary care providers could be analyzed for gaps. Interventions to the gaps could be funded with expectations toward sustainable operations.
•  Knowledge and education on scheduling, administration, storage and handling is notable and should continue to be funded.
•   Reimbursement opportunities between government payors and medical homes, if there are any, could be clarified with respect to IPV.
•  Immunization administration refreshers should be an educational opportunity accessible by all licensed care providers, including LVNs and RNs, in the local jurisdiction. It is not enough to say a nurse should know how to give a shot. That concept divorces immunization from professionalism, dissolves subject matter expertise and diminishes the specialty of the care. Nurses and clinicians who vaccinate should know how to vaccinate, and nurses and clinicians who don’t know how to vaccinate should not vaccinate. Period.
• WHO recommendations for countries with and without local transmission of polio include the US [8] due to recent polio detection. These points, such as immunization coverage and surveillance cooperation, should be decided on and continuously evaluated.
• Planning for the WHO recommendations if transmission occurs (traveler documentation, targeted doses, Advisory Group coordination) should begin now, not after the fact [8].
• Criteria for enhanced activities in the US could have consensus to either match WHO or take a more conservative approach.
• Water, sewage and other environmental surveillance and prevention factors could be analyzed for prevention work gaps [11]. State comparisons and collegiality to improvement could be examined.
• USAID and any other government-sponsored polio prevention international funding should be tied to metrics that are consistent across nonprofit and global health polio efforts.
• ASTHO, NACCHO, APHA and other organizations could assess for labor and epidemiology inconsistencies and needs across states, as well as in the international arena.
• ASTHO, NACHCO, APHA and federal government could seek improvements in immunization data technology.
• A strategic plan to tackle projected declining immunization rates should be clear, from a national to regional to global scope [12,13].
• Immunization rates for children in US military families may or may not be match to the general US population. Research and military statements are conflicting, and it’s unclear how the polio immunization statistic could be easily obtained for the military family population. Consensus around best approach to the data is also unclear, especially during a period of pandemic-related setbacks amid continuing military moves. Because the data is not clear, the need for improvement is also unknown. Lack of clarity to the data and unknowns around accuracy of the data have complicated an otherwise simple aspect to polio prevention.
• Separation between global health assistance and geopolitics, including special US security operations, should be honored. There should be no room for deceit with vaccines, including from US special forces and from US clandestine work. If vaccine programs cannot be respected, they should be reassigned under other leadership. Agencies including the State Department should be accountable for unprofessionalism and poor decision-making. There is no room for deceit with vaccines. 

Simply put. the world continues to excel with polio prevention and eradication. We are not where we need to be yet. Sustained financing with continued improvements to polio campaigns will get us there. 

 

References

1. https://www.who.int/publications/m/item/mid-term-evaluation-of-the-implementation-of-the-strategic-action-plan-on-polio-transition-(2018-2023)--management-response---september-2022

2. https://polioeradication.org/gpei-strategy-2022-2026/  

3. https://www.gavi.org/vaccineswork/tag/polio 

4. https://www.gavi.org/vaccineswork/crossroads-polio-eradication-experience-india-shows-why-still-achievable 

5. https://www.rotary.org/en/our-causes/ending-polio

6. https://polioeradication.org/financing/polio-eradication-pledging-moment-18-october-2022/

7. https://www.endpolio.org/donate

8. https://www.who.int/news/item/01-11-2022-statement-of-the-thirty-third-polio-ihr-emergency-committee

9. https://www.cdc.gov/nchs/fastats/immunize.htm

10.   https://abcnews.go.com/Health/us-states-highest-lowest-polio-vaccination-rates/story?id=88539770

11. https://newscast.astho.org/270-tracking-polio-in-new-york

12. https://abcnews.go.com/Health/us-states-highest-lowest-polio-vaccination-rates/story?id=88539770

13. https://www.paho.org/en/news/23-2-2022-paho-urges-increased-polio-vaccination-children-americas 

Climate and Environmental Health Impacts on Human Health

Global health has matched the global interest in climate health advocacy. Global health has the opportunity to enhance partnership with the healthcare industry, as well as assume a liaison role between healthcare and non-healthcare industries.

• The definition of climate health, as opposed to climate-related environmental health that impacts the public, should be used consistently and with clarity. Climate health could be devoted to the health of the climate, including mitigation of climate change. This is completely separate than climate-related environmental health that acutely impacts life.
• The unnecessary gray areas between environmental health responsibilities and climate change responsibilities can be clearer. Climate-related environmental health and actions to mitigate climate changes (flood risk preparedness inclusive of water-borne illness preparation), as opposed to environmental health in the public health realm (restaurant inspections, pool inspections, waste management), can be better organized.
• Global health has instituted new resources for climate health within the public health realm [1]. This is an opportunity to create structure.
• Distinction between mitigation, response and climate change prevention work would help.
• Distinction between everyday environmental public health and emergency preparedness would help. 
• Standardization of burden methodology and standards to interventions would also help. The statistic provided by climahealth.info is very misleading [2]. That every year, environmental factors “take the lives” of 13 million people is misleading. This statistic includes everything from occupational injuries resulting in HIV transmission to self-harm from access to chemicals. The data source fails to be thorough in catastrophic climate events as well; the report doesn’t detail housing, food and medication supply disruption from a flood or hurricane.
• The climahealth movement is admirable and new [2]. With this:
• There is opportunity to describe and align specific categories of human health burden.
• There is opportunity to gain consensus on formulas for estimation.
• There is opportunity to distinguish between environmental public health and climate change response. The difference between decades-old programs in mosquito abatement and new needs in vector-borne illness prevention matter. The difference between asking public health to advocate for reduced traffic pollution and asking public health to respond to cancer surveillance epidemiology is stark; these issues may involve the environment yet needn’t be grouped under the same oversight.
• Stronger epidemiological oversight is necessary when a country faces a major climate catastrophe. This is an area where new global climate health organization can lead, specifically with response levels and standardized data collection tools. It matters if a hurricane in the United States disrupts pharmaceutical access for 5 days and if a flood in a LMIC disrupts pharmaceutical access for 6 months.
• The opportunity for capacity assessments from burden and projection formulas should be taken. It matters if the manufacturing or trade capacity of a country is prepared for projected asthma medication needs, or not.
• Tasks, quality improvement metrics and actions specific to healthcare buildings, healthcare environments, health industry needs (asthma medications, etc) and medicine would assist the healthcare industry. Tasking is lacking because the broader issues of climate and environment are not organized, and because there is confusion between healthcare participation in climate change mitigation versus environmental health. Also, there may be a disconnect between what climate advocates are passionately messaging and what public environmental health is already overseeing.
• Climate change mitigation responsibilities in healthcare should be logical.
• Structure to energy efficiency and ecofriendly efforts by the healthcare industry should be actionable and measured.
• The serious disconnect between language messaged and healthcare priorities for patients should be acknowledged. The picture of a dramatic actor playing a physician, a physician more concerned about saving a trauma patient’s life than the unnecessary plastic waste used or energy inefficiency during care, isn’t fiction. In real life, the recent pandemic disrupted ecofriendly policies right before the public’s eyes. We experienced an immediate backburner placement of climate concerns because the acute priority of surviving is inherent. This is a reality that many in healthcare live every day, beyond pandemics. It is not enough to calculate balances, such as the offsets between low traffic pollution to plastic cups. Global health leadership needs to get serious about the healthcare industry and the public’s priorities: life will always take urgent precedence, there will always be a life-saving need, and physician and industry leadership will refocus whenever and wherever acute care is needed. A clear and better plan to mitigate climate change involving healthcare should relieve the burden from those who won’t hesitate to choose. In other words, what is the plan for automatic ecofriendly workarounds moving forward? Let’s concur, so healthcare can do its part, and so healthcare can maintain integrity to medicine’s priorities while doing so.

 

US national healthcare has increased attention to climate change and climate-related environmental health.

• Health impacts from climate and environment issues are clarified by the CDC [3]. Evidence strength is also specified and is welcomed.
• Clarity to the differences between environmental health and climate change concerns is an opportunity. Avoiding the wanton entrance of political and social conversations about what is manmade and what can’t be helped can be accomplished with commitment to objective health conversation. When clarity between what to expect from basic environment is teased out from climate change course, objectivity steers health planning.
• Data and methodology validation and standardization would be helpful.
• How this methodology is applied by states and municipalities is unclear. References for the data projection [4] and formulas would be helpful. For example, it is helpful to understand if the formula that the CDC uses to project increased asthma cases in the Midwest mirrors formulas used by local, state and global health organizations [5].
• Resources provided by the CDC are very different than those provided by national public health organizations, including APHA [6,7]. Messaging is also different. There is no justification for public health to be all over the place with climate-related environmental health issues.
• Healthcare’s responsibilities to climate change preparation and mitigation are intentionally opaque and inattentive. “Resources for health departments” truly is no longer good enough.
• Building and engineering requirements for hospitals, pharmaceutical manufacturers and other structures is a shared responsibility beyond “health departments”.  The tool used for energy assessment shared by APHA may or may not be supported by major engineering and construction organizations [8]. It is unclear how public health, private healthcare, construction and engineering are aligned on ecofriendly structure.
• Environmental health issues may see flexed oversight as climate-related environmental health issues draw more attention. Waste management requirements, city policies (such as reduced traffic in busy pedestrian areas) and local environmental designing (to mitigate vector borne illness, reduce energy use) are a shared responsibility yet should have designated oversight. This is the oversight that “health departments” should be able to go to for direct information and response.
• Climate-related environmental health issues that impact physical medicine also require acceptance and accountability from industries and their lobbyists, including for medicine and healthcare delivery access. Increased asthma projections and increased vector-borne illness also place responsibility on higher education for the supply of clinicians, pharmaceutical planning for generics and competition, and insurance industry preparation. Climate Capacity [9] messaging by ASTHO could also be supported by specifics on clinical medicine needs.
• Clarity to environmental health oversight (versus medical or clinical oversight) could be clearer. An analysis of local and state public environmental health needs and capacities, credentialing, quality accreditation and reliance on private contracting would be a good start.
• Major frameworks used by the CDC, and funded as grant work to states, are organized. BRACE [10] is organized, reference by evidence and it is logical. Yet frameworks are inconsistently applied.
•  BRACE is not mirrored by states, national public health administration groups or national public health associations.
• It is unknown if BRACE or any other framework is assessed when accrediting towns, counties, municipalities or public health departments with various quality accreditation.
• Distinction between Emergency Preparedness, Clinical Public Health and Environmental Public Health should be clear in action planning. They are currently thrown into the messaging with little regard for organization and standardization across private and public organizations.
• It is unclear how climate health intervention assessments are teasing out basic environmental health from climate change intervention. The CDC’s intervention documents [11] can and should improve distinction.
• Concerns related to gradual change or catastrophic climate events involve other national and state departments, yet a strategic and cohesive gameplan is absent. These concerns usually include heating and cooling, water, food supply, and housing. Leaving it to the “health department” is wildly inappropriate and negates the work of these other agencies. It also sets us all up for a confused rollout with inefficiencies, duplication of response and gaps in response. When broader issues are at stake, such as agriculture, there is usually no multi-agency collaboration that involves local health either. 
• Mapping and maps for ecological health, impacts to human health and human health projections should be standard. As it is, map use in organizations and advocacy are as scattered as the populations and geographies they reference.
• The US military has played a strong leadership role in climate change and human health impact science, yet it is unclear how they are involved on an ongoing basis. Involvement with improvements to climate-related environmental health concerns can and should be familiar. A familiar involvement between the US military and the US civilian structure is that of leadership, hierarchical structure and organization where organization lacks. The US military can and should model what it does best, helping the US 'get it together' (so to speak).

 

References

 1. https://www.who.int/news/item/31-10-2022-who-and-wmo-launch-a-new-knowledge-platform-for-climate-and-health

2. https://climahealth.info

3.  https://www.cdc.gov/climateandhealth/site_resources.htm

4.  https://www.cdc.gov/climateandhealth/docs/ProjectingClimateRelatedDiseaseBurden_508.pdf

5.  https://www.cdc.gov/climateandhealth/effects/Midwest.htm

6.  https://www.cdc.gov/climateandhealth/site_resources.htm

7. https://www.apha.org/topics-and-issues/climate-change

8. https://www.apha.org/topics-and-issues/climate-change

9.  https://www.astho.org/topic/environmental-health/climate/

10. https://www.cdc.gov/climateandhealth/BRACE.htm

11. https://www.cdc.gov/climateandhealth/docs/ClimateAndHealthInterventionAssessment_508.pdf

Lead Exposure

Lead exposure remains a serious concern worldwide. Lead exposure prevention and management is a priority across disciplines, yet a transparent, unified and sustained progress goal remains elusive.

Global work on reducing and elimination lead in the environment has been great. Collaboration between global health, environmental protection, international law and international advisory councils [1,2,3,4] is truly remarkable.

•  It would be helpful to know who is responsible to guide goals, metrics and evaluation of lead exposure prevention worldwide.
• Metrics assigned to legal advice and consultation could support advancement.
• A plan to involve the trade industry would benefit lead prevention and mitigation efforts, worldwide.
• A plan to compare countries’ occupational surveillance for lead [5], as well as other occupational measures, could also assist.
• A comparison of country resources compared to country results should be undertaken without delay. This is an issue that effects all countries. Continued lead exposure, despite resources at disposal, should question lead programs and interventions.

US national efforts in lead exposure prevention, mitigation and management also continue.

• Consensus on data use and methodology or exposure surveillance should be sought [6].
• A unified goal to address racial and other disparities should be clear [7,8].
• Consensus on costs should also be clear. For decades, we continue to experience failures with lead exposure.
• Where are the national and state cost estimates on infrastructure replacement, new product requirements and waste management?
• Where are the cost estimates on lead surveillance for pediatric populations and adult occupational exposure, beyond physician referrals? 
• What is the estimated cost for implementation and ongoing local and state HiAP efforts for lead prevention [9,10]    
• Consensus on medical management, particularly when it is questioned in the public, should be available [11]. The question of what the medical community can do to improve consensus, thereby improving public trust, should see response.
• Clear and streamlined public health strategies should be clear.
• NACCHO and ASTHO have similar messaging for some lead programs [12,13]. How they work together to provide standard recommendations for public health administration should be clear. Annual evaluation plans for the recommendation and implementation should also be clear.
• Agencies including CDC, EPA, HUD have shared meetings. How they work with OSHA and other agencies to streamline lead exposure management [14,15, 16] should be known. How these agencies have streamlined household referrals to local and state public health resources, as well as streamlined referrals for medical consultation, should be mapped. Agencies should be tasked with household resource navigation supervision.
• Streamlined state processes should lessen the burden on the public. What state forms and processes can be better streamlined [17,18], so that public messaging is familiar regardless of state moves?
• A strategic gameplan for state improvement, evaluated nationally, could assist progress.
• Case examples and information sharing are available and could be cataloged [19].
• Local and state EHS public health action summaries are available and could also be cataloged [20].
• Long term plans, such as an Environmental Public Health Tracking (EPHT) portal, could detail goals for states and territories [21].
• Experienced public health program professionals could be tasked with consensus around recommending specific improvements for lead exposure prevention across public health agencies, medicine and other industries.
• Public health should improve a gameplan that shifts burden solely off of parents, households and individuals.
• When individual behavior change is asked of the public, [22,23] public health must reciprocate with accountability. Requirements of public administrations, employers and the medical community, should be transparent.
• Navigation of various state regulations, and failure to efficiently standardize regulation workflow, should also be a consideration that lessens household burden [24].
• Lead testing metrics should improve. The number of households requesting lead testing is not reported on. The CDC data refers to physician-determined testing [25], yet what about those who choose to test their homes? What has been the taxpayer cost to requests and delays?  Once tests are completed, have the resource referrals been standard and equitable for high level results, regardless of geography? Better data can and should drive expectations [26].
• Occupational health and workplace safety around lead exposure could be better unified.  Metrics to assess occupational health could be standardized alongside housing and environmental protection. Infrastructure pushes, such as lead in building materials, could be included as a workplace safety consideration. Military occupational health could be included in greater public health reporting, with lead exposure and management as a leading partnership.
• Legal consequences for private, employer, pediatrician and public administration officials who ignore lead safety should be clearer. Consequences for the US military, when lead prevention and management interventions are ignored [27,28], should also be clearer.

 

US military lead abatement and lead management efforts continue.

• Military interventions resulting from public relations investigations around lead exposure are a first step [29], as are government accountability audits [30,31]. How the need for an intervention at one military site or sector translates to intervention assessment across sites is unclear, however. It’s also not clear how lead issues are prevented across military systems once discovered in one area. 
• Civilian infrastructure involvement could be clearer.
• State accounting for lead exposure in military households [32] is not known. It is not clear if base data is included in public health consistently.
• How the CDC and pediatrician community accounts for military families in data and tracking is also unknown [33].
• Occupational lead exposure leadership is an opportunity yet to be realized between civilian and military research [34,35]. It is also an opportunity to partner better with OSHA, EPA and public health. This opportunity should be taken.
• Data on lead exposure concerns from military members and from their medical professionals is unknown. What concerns from active duty and veteran hotlines have been documented, what resources were utilized and how many denials were there [36,37]? Given the serious, persistent and oft-accepted health damage from lead exposure, surveillance, oversight and urgency to interventions could be must stronger.

 

References

1.   https://www.who.int/campaigns/international-lead-poisoning-prevention-week/2022

2.    https://www.unep.org/explore-topics/chemicals-waste/what-we-do/emerging-issues/global-alliance-eliminate-lead-paint

3.   https://www.who.int/news/item/23-10-2022-almost-1-million-people-die-every-year-due-to-lead-poisoning--with-more-children-suffering-long-term-health-effects

4.    https://wedocs.unep.org/bitstream/handle/20.500.11822/37711/GPAAP21-23.pdf?sequence=3&isAllowed=y

5.    https://academic.oup.com/milmed/article/181/9/1121/4159842

6.    https://www.pnas.org/doi/10.1073/pnas.2118631119

7.    https://pubmed.ncbi.nlm.nih.gov/33394180/

8.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522252/

9.    https://www.astho.org/globalassets/report/implementing-a-health-in-all-policies-approach-to-lead-poisoning-prevention.pdf

10.  https://www.naccho.org/uploads/downloadable-resources/HiAP_LPP_Recommendations-FNL.pdf

11.  https://www.military.com/daily-news/2019/04/04/these-us-troops-are-slowly-being-poisoned-lead-their-bones.html

12.  https://www.naccho.org/uploads/downloadable-resources/HiAP_LPP_Recommendations-FNL.pdf

13.  https://www.naccho.org/blog/articles/addressing-childhood-lead-poisoning-with-health-in-all-policies-strategies

14.  https://www.naccho.org/blog/articles/take-action-during-national-lead-poisoning-prevention-week

15.  https://www.cdc.gov/nceh/lead/default.htm

16.  https://www.apha.org/News-and-Media/News-Releases/APHA-News-Releases/2021/APHA-Backs-White-House-plan-to-remove-lead-pipes

17.  https://www.dhs.wisconsin.gov/lead/ph-intervention.htm

18.  https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/Lead-Poisoning.aspx

19.  https://www.astho.org/communications/podcast/improving-care-to-address-maternal-child-lead-exposure/

20.  https://www.astho.org/globalassets/pdf/childhood-lead-poisoning-prevention-and-control-results-factsheet.pdf

21.  https://www.astho.org/globalassets/pdf/epht-fellowship-presentation-tn-lead-poisoning-index.pdf

22.  https://www.apha.org/News-and-Media/News-Releases/AJPH-News-Releases/2022/AJPH-September-Lead-Supplement

23.  https://www.apha.org/Events-and-Meetings/Webinars/Lead-and-Public-Health

24.  https://phc.amedd.army.mil/topics/workplacehealth/ih/Pages/leadproviders.aspx

25.  https://www.cdc.gov/nceh/lead/data/index.htm

26.  https://www.apha.org/News-and-Media/News-Releases/AJPH-News-Releases/2022/AJPH-September-Lead-Supplement

27.  https://www.osc.state.ny.us/files/state-agencies/audits/pdf/sga-2020-19s50.pdf

28.  https://www.reuters.com/investigates/special-report/usa-military-housing/

29.  https://www.armytimes.com/news/your-army/2018/08/17/report-finds-kids-in-army-housing-at-risk-of-lead-poisoning/

30.  https://www.osc.state.ny.us/files/state-agencies/audits/pdf/sga-2020-19s50.pdf

31.  https://www.reuters.com/investigates/special-report/usa-military-housing/

32.  https://www.militarytimes.com/pay-benefits/2022/07/26/dod-hasnt-properly-tracked-lead-exposure-in-military-kids/ 

33.  https://www.militarytimes.com/pay-benefits/2022/07/26/dod-hasnt-properly-tracked-lead-exposure-in-military-kids/

34.  https://www.stripes.com/theaters/europe/army-special-operations-troops-have-lower-blood-lead-levels-after-firing-range-fixes-study-finds-1.668175

35.  https://health.mil/News/Articles/2021/03/01/Blood-levels-MSMR-Mar-2021

36.  https://www.publichealth.va.gov/exposures/lead/index.asp

37.  https://phc.amedd.army.mil/topics/workplacehealth/ih/Pages/Lead.aspx 

Cholera

Global health understands that cholera is a critical, urgent issue. Global, national and local collegiality are ready and committed to tackle the issue. Ongoing work should be championed without delay.

Global health provides streamlined navigation for cholera control. The World Health Organization (WHO) highlights emergency kits, outbreak management and vaccination in materials [1]. WHO also refers to a unified global task force, and this clearly communicated navigation is greatly appreciated.

The Global Health Task Force on Cholera Control (GHTFCC) has a strong leadership steering course [2]. The 2030 roadmap is specific, particularly the cost presentation, burden and indicators on progress. 

• The roadmap was published in 2017 and it’s unclear if the 2017, 2018 and 2019 timeline action items were actually accomplished. It’s also unclear if the 2020 outcome indicators (Appendix C) were met for 2020 [3].

• Financing the water, sanitation, and hygiene (WASH) initiatives is complex. The Roadmap points to a 2019 stakeholder meeting on cholera control WASH funding. The decisions and outcomes from the meeting are unknown, including what’s left unfunded, how funding is tracked, how programs are audited, how those not eligible for GAVI programs are included, how much of the burden is not covered by other programs and how corruption is avoided. Despite formal handoff to WaterAid, these items do not appear to be publicly available and may not have been assessed [4].

• How WHO works with cholera kits and cholera vaccine assistance could be clearer. Where WHO work can better merge, if applicable, could also be clearer.

• The Country Support Platform for cholera management may or may not align with other epidemiological programs with standardized templates for individual country data. How these templates are streamlined, as well as how global health and global policy organizations access the most accurate data, is unknown.

• Inclusion of labor, education and training of professional epidemiologists is an opportunity for action plans, and for formal outcome measures.

The United States continues to support cholera control worldwide through public and private aid, research and medical labor overseas. 

• It is not clear how medical missions work are aligned with national and global health plans for cholera control. It is not clear if they use the same materials, contribute to the data or even if funding and volunteer labor is factored into global reports. Financial and quality of practice audits are also absent in medical missions work, and absent for cholera contributions [5,6].

• How the CDC aligns with the GHTFCC is not clear, nor is GHTFCC referenced at the CDC [7].

• There is a major gap around national association, Department of State/USAID efforts and other infrastructure WASH support. How construction, facilities, sewage and sanitation expertise are built is not clear. Any labor and staffing assessments that may have been conducted, or if alignment of the assessments alongside GHTFCC, is not described.

• Research priorities for cholera are clear for a national department yet unclear in an international strategic research gameplan. NIH and partners may be potentially maligned. Therapeutics focus could be an international gameplan, particularly with intellectual property and financing considerations down the line [8,9].

• Direct cholera aid and healthcare provided by federal agencies and national organizations could be clearer, including aid provided through military assistance. 

Cholera work is dedicated and strong. Global health should adopt a less tolerant approach to ongoing cholera disease, everywhere. It’s quite unacceptable to continue at a slow pace of change. 

References

1. https://www.who.int/news-room/fact-sheets/detail/cholera

2. https://www.gtfcc.org/ 

3. https://www.gtfcc.org/about-cholera/roadmap-2030/

4. https://www.gtfcc.org/news/zoom-on-wateraid-chair-of-the-gtfcc-wash-working-group/

5. https://www.pqmd.org/emergency-aid-yemen-cholera-food-insecurity/ 

6. https://umcmission.org/september-2022/stopping-the-spread-of-cholera-in-north-katanga/

7. https://www.cdc.gov/cholera/africa/locations.html

8. https://www.niaid.nih.gov/diseases-conditions/cholera-treatment-and-prevention

9. https://www.niaid.nih.gov/diseases-conditions/cholera