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Disaster, Water, Cholera, Vaccines, and Hope
http://www.100md.com 《新英格兰医药杂志》
     The world is now all too familiar with images of the destruction caused by the tsunami that struck Southeast Asia on December 26 of last year. In a natural disaster, there are three stages of injury: injury or death when the disaster strikes, survival of the immediate threat but death from injuries induced by the event, and illness and death due to diseases that arise from the destruction of the public health infrastructure. Now, two months after the tsunami, and after the recorded deaths of more than 150,000 people, the world is poised to see whether the third stage will materialize.

    Contaminated drinking water is one of the major sources of rapidly spreading diseases after natural disasters. Ensuring the availability of clean water involves establishing a system for the supply and distribution of this water, treating the water to remove microbial contaminants, providing a sanitation system that separates waste from the water supply, and encouraging hygiene, such as hand washing, that keeps clean water safe for individual use. Since the tsunami, all these components have become vulnerable, and all have become top public health priorities.

    Cholera, caused by the curved bacterium Vibrio cholerae, is one of most feared epidemic diarrheal diseases. The natural habitat of V. cholerae is an aquatic environment. Under conditions with the right temperature, nutrient supply, and salinity, these bacteria multiply explosively, creating the potential for rapid waterborne spread and a cholera epidemic. The tsunami led to these conditions. Because the public health infrastructure that makes clean water available may not be restored quickly, the possibility of a cholera epidemic is real. In this issue of the Journal, Lucas et al.1 report the results of a large case–control study of a cholera vaccine that appears to be highly protective, especially against the more severe forms of the disease. The study was performed in Mozambique, where cholera is endemic and predictably occurs during the annual rainy season. Under these real-world conditions, the data on the oral vaccine suggest that it could curb "third-wave" deaths due to cholera.

    Of course, a vaccine can work only if it is available, and the first steps toward availability are manufacture of the vaccine product and its preparation for use. In this regard, the Swedish government has announced that it will provide, at its expense, to the World Health Organization enough vaccine for 200,000 people. The Swedish government and its National Bacteriological Laboratory (SBL Vaccines), the vaccine manufacturer, deserve credit and praise for taking this step.

    The world has opened its heart to the survivors of the tsunami. As of the beginning of February, the availability of clean water and adequate sewage disposal seem to have prevented a major outbreak of cholera. However, should health officials determine that preemptive vaccination is indicated, the gift of the vaccine to the tsunami survivors could help prevent an outbreak of cholera and cholera-related deaths. If this approach is needed, we hope that the World Health Organization will be able to mobilize the resources needed to distribute the vaccine in areas where it will do the most good.(Jeffrey M. Drazen, M.D., )