Prevention and Control of Cholera in Africa:
Policy Implications of Implementing an
Oral Cholera Vaccination Campaign
in Nsanje, Malawi
vorgelegt von
MPH
Amber Hsiao Hyman
ORCID: 0000-0003-2295-0886
an der Fakultät VII – Wirtschaft und Management
der Technischen Universität Berlin
zur Erlangung des akademischen Grades
Doktor der Gesundheitswissenschaften/Public Health
(Dr. P.H.)
genehmigte Dissertation
Promotionsausschuss:
Vorsitzender: Dr. Reinhard Busse
Gutachter: Dr. Wilm Quentin
Gutachterin: Dr. Manuela De Allegri
Tag der wissenschaftlichen Aussprache: 19. Dezember 2022
Berlin 2023
Table of Contents
Chapter 1: Introduction .................................................................................................... 3
1.1 Introduction ........................................................................................................ 3
1.2 Epidemiology of Cholera .................................................................................... 6
1.3 Cholera Control and Prevention ......................................................................... 9
1.4 Health Economics ............................................................................................ 10
1.5 The Importance of Health Systems .................................................................. 11
1.6 Purpose and Organization of the Dissertation .................................................. 15
1.6.1 Objective 1: Provide an overview of the existing literature on the cost of
illness of cholera and the cost-effectiveness/cost-utility of oral cholera vaccines... 15
1.6.2 Objective 2: Estimate the costs of cholera illness in Nsanje, Malawi ......... 16
1.6.3 Objective 3: Assess the cost-effectiveness of oral cholera vaccines in
Nsanje, Malawi ....................................................................................................... 17
1.6.4 Objective 4: Analyze the relationship between corruption and access to
healthcare in Africa ................................................................................................ 17
Chapter 2: Health Economics of Cholera Illness & Cholera Vaccination ....................... 18
Objective 1: Provide an overview of the existing literature on the cost of illness of
cholera and the cost-effectiveness/cost-utility of oral cholera vaccines ..................... 18
Chapter 3: Cost of Illness .............................................................................................. 40
Objective 2: Estimate the costs of cholera illness in Nsanje, Malawi ......................... 40
Chapter 4: Cost Effectiveness of OCVs in Nsanje, Malawi ........................................... 49
Objective 3: Assess the cost-effectiveness of oral cholera vaccines in Nsanje, Malawi
................................................................................................................................... 49
Chapter 5: Corruption & Healthcare Access in Africa .................................................... 75
Objective 4: Analyze the relationship between corruption and access to healthcare in
Africa ......................................................................................................................... 75
Chapter 6: Discussion ................................................................................................... 88
Implications of Research ........................................................................................... 93
Conclusions ............................................................................................................... 97
Appendix I: List of Primary Publications ........................................................................ 99
References .................................................................................................................... 100
Chapter 1: Introduction
1.1 Introduction
The Sustainable Development Goals (SDGs) are a global blueprint that has been
adopted by all United Nations (UN) Member States in 2015 to guide countries toward a
universal set of goals in an effort to meet the needs of the world’s poorest.1 The SDGs
are broken down into 17 larger, overarching goals, many of which are interconnected
and also directly tackle health issues, such as health and well-being, clean water and
sanitation, and zero hunger.
Despite global improvements in a number of areas, such as child and maternal health,
management of diseases, and health systems and funding, premature death and
preventable morbidity still occur. Much of this burden is in middle- and low-income
countries, particularly in sub-Saharan Africa. While rates of communicable diseases
have decreased dramatically throughout the decades, diarrheal diseases still account
for a substantial numbers of deaths and disability.2 In children under the age of 5
especially, diarrheal disease is a leading cause of preventable death that kills an
estimated 446,000 globally, and over two-thirds of these deaths occur in sub-Saharan
Africa.3
3
The two leading causes of diarrheal deaths are rotavirus and Shigella, causing 212,438
and 228,047 deaths in 2016, respectively.3, 4 Vibrio cholerae (cholera) is the third
leading cause of death, which caused 107,290 deaths in 2016. The greatest burden of
rotavirus and cholera are in children aged <5 years, which has detrimental effects
beyond the duration of illness. Persistent diarrhea especially during childhood is
associated with malnutrition and stunted growth,5, 6 and the early effects of stunting do
not appear to be fully reversible later in life.5 In adolescents and adults, diarrhea tends
to be less severe,7 but apart from the illness itself, there are indirect costs in the form of
economic and educational consequences, such as missed days of school and/or work
and loss of income. Further, there is evidence that suggests that there is a link between
poor weight gain in childhood due to diarrheal illness and a greater likelihood of chronic
disease in adulthood, including diabetes, obesity, hypertension, and cardiovascular
disease.6
While diarrheal illness occurs in countries of all income levels, it disproportionately
affects areas with poor access to water, sanitation, and hygiene (WASH), and limited
healthcare infrastructure and access to care.3 Studies have estimated that 88% of
diarrheal-associated deaths can be attributed to inadequate WASH practices,8-10 and
are therefore largely preventable.
There are two key SDGs that outline interconnected sub goals that move progress
toward reducing diarrheal illness globally. SDG 3 is to ensure healthy lives and promote
well-being for everyone at all ages. There are a number of sub goals, including: ending
4
preventable deaths in children aged <5 years (goal 3.2), achieving universal health
coverage (UHC) (goal 3.8), supporting the research and development of vaccines and
medicines for communicable and non-communicable diseases that affect developing
countries (goal 3.b), and substantially increasing health financing and
recruiting/retaining a skilled healthcare workforce (goal 3.c).1
SDG 6 is also critical to ensure the availability and sustainable management of water
and sanitation for all. Significant progress has been made toward this goal: more than
half the world’s population now has access to piped water connections in the home.11
However, 748 million people globally still lack access to clean water, and 325 million
(43%) of these people live in sub-Saharan Africa.11 In addition, nearly 2.5 billion people,
or 37% of the world’s population, lack adequate sanitation.12-14 Consequently,
approximately 3.5 million people die annually of the consequences of water-related
diseases due to poor water supplies, sanitation, and hygiene.15 Among the regions of
the world, Southern Asia and sub-Saharan Africa consistently have some of the lowest
coverage rates in access to improved sanitation: 42% and 30%, respectively (compared
to Eastern Asia at 67%, which is largely driven by China).11 One billion people, 82% of
whom live in middle-income countries, still practice open defecation, which may leach
into ground water.11, 16 As a result, an estimated 1.8 billion people drink water that
contains fecal contamination that may have dire consequences for human health. Often,
those impacted are from severely impoverished communities.11, 14, 17, 18 Such disparities
have consequences for disease transmission, particularly diarrheal and enteric
diseases.
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