What lies ahead Clearly the extremely ambitious goals

What lies ahead? Clearly the extremely ambitious goals and targets set by the UNCoLSC have not been reached, and challenges must be overcome. While the current evaluation highlights several challenges and strategies for action, a clear process in moving forward would be to link this bottleneck analysis to the new global strategy for Every Woman Every Child, and therefore remain relevant to the Sustainable Development Goals. Can this work be linked to the financing opportunities and country-level microplanning being undertaken by the global financing facility of the World Bank? How can the work on commodities connect to the principles of universal health care, equity, and accountability, fundamental to the Sustainable Development Goals? It is time to move beyond the diagnostic to focus a lot more on implementation and achieving effective coverage.
On Dec 23, 2015, WHO prequalified a second affordable oral cholera vaccine (OCV), Euvichol (Eubiologics, South Korea), which is expected to double current global OCV production and has the potential to further increase production capacity. The increased production will have implications for vaccine availability and reduced costs per dose, and will ultimately represent an added value for global cholera prevention and control. Vaccine prequalification is a WHO-led activity intended to ensure that vaccines purchased by UN procurement agencies will be acceptable under conditions of use in national immunisation programmes in low-income and middle-income countries (LMICs). Prequalification also indicates that a vaccine meets WHO recommendations for quality, safety, and efficacy—enabling wider implementation of the vaccine in resource-limited contexts. Cholera is endemic in more than 50 countries, with an estimated at-risk vegfr inhibitor of 1·5 billion, plus an annual estimated morbidity of more than 2 million cases and nearly 100 000 deaths. However, public attention is only garnered when outbreaks strike disaster-ravaged areas. Successful cholera control depends on a long-term commitment to improve water quality and sanitation systems, but an effective vaccine serves as an important component in a comprehensive prevention package. In 2001, WHO prequalified the OCV Dukoral (SBLVaccin, Sweden) for purchase by UN agencies. Through a successful technology transfer agreement, a modified bivalent formulation, Shanchol (Shantha Biotechnics, India), was developed and manufactured and was prequalified in 2011. Both Shanchol and the newly prequalified Korean vaccine (Euvichol) are reformulated versions of Dukoral. Because these newer versions do not contain the cholera toxin, they do not require co-administration with an oral buffer, making these versions both easier to deliver in challenging field conditions and substantially less costly for the standard two-dose regimen (US$3·7 for Shanchol and Euvichol >$10·5 for Dukoral). In July, 2013, a global OCV stockpile was created. A stockpile is a mechanism to encourage change in vaccine use for underserved populations: a change from low demand, low production, high unit costs, and inequitable distribution, to an increased demand and production, lower unit costs, and greater equity of distribution. The Gavi Alliance approved funding of US$115 million from 2014–18 for a global stockpile delivery strategy for use in epidemic and endemic settings. Since inception, 21 shipments of OCV have been approved to be used in large preventive or reactive vaccination campaigns (about 4 million doses) in 11 countries. Because of limited supply, OCV is released from this stockpile after review and recommendation of country applications by the International Coordinating Group, composed of UNICEF, Médecins Sans Frontières, The International Federation of Red Cross, and WHO. The vaccine has been used successfully in various contexts—humanitarian crises (eg, South Sudan and Ethiopia), disease outbreaks (eg, Guinea, Malawi, Tanzania, and Iraq), and endemic hotspots (eg, Bangladesh, Democratic Republic of Congo, and Haiti).