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Not a Safe Drop to Drink without Clean water and proper sanitation, Many Zambian fishermen and their families are at Serious risk FOR cholera. a study aims to find better ways to protect them.

Nearly every year for the past 40, the landlocked African nation of Zambia has suffered from repeated outbreaks of cholera, an acute diarrheal disease that can lead to dehydration and death if not treated properly. The most common cause: Drinking water contaminated with human waste.

Here in the Lukanga swamp, finding clean water to drink is a challenge, particularly for the many fishermen who depend on the rivers for their livelihoods. They often live on the water for weeks at a time in makeshift camps on floating islands called Ichitolo in the local language. Back home in the village, their families struggle to find clean water. The community water system has been broken for months because the repairs are so costly.

When the fishermen are living on the water, they spend their days on wooden boats and their nights sleeping in huts made of straw or grass that need to be relaid daily to prevent them from sinking. With the lack of solid land inside the swamp, there is no way to build a proper sanitary latrine.

The result is that they fish and drink from the same water they use as a toilet, creating an environment where cholera outbreaks are more a matter of when and not if.

These conditions underscore the need for additional preventive measures: A safe, affordable, two-dose oral vaccine is being widely used to prevent cholera in areas at risk.

The vaccine is 65 percent effective for at least three years and up to five years where cholera is most common. Yet, despite a steady increase in supply, there are not always sufficient doses for all in need, especially in an outbreak. Additionally, the standard two-week period between doses is a challenge in areas such as the Lukanga swamp, which is made up of 13,500 square kilometers and 19 lagoons. Fishermen say it takes two days to cross the swamp by motorized boat, which they seldom have, and considerably longer by canoe. It takes more than a month to cover it in its entirety.

Given these challenges, decision-makers have chosen to vaccinate more people with one dose each initially to suppress the outbreak rather than covering half the population with two doses given the standard two weeks apart. The second dose is then provided as soon as it becomes available — often several months after the first dose.

The question is: How long will this protect people from cholera?

Funded by the Bill & Melinda Gates Foundation, the Delivering Oral Vaccine Effectively (DOVE) project at the Johns Hopkins Bloomberg School of Public Health works globally to distribute oral cholera vaccine to the people most in need. The Johns Hopkins Center for Communication Programs supports these efforts.

A joint research study between the DOVE project and the Centre for Infectious Disease Research in Zambia is being conducted to determine if the second dose can be delivered at longer intervals and if it provides the same or even better protection at six months when compared to the standard two weeks. This is the first study of its kind.

The study participants are mostly fishermen and their families who live in the Waya Health Clinic District.

Along with getting two doses of the vaccine, participants provide a small blood sample before and during the study to assess protection at the different dose intervals.

“We are very grateful for the cooperation of the people in Lukanga swamp for their willingness to partner with us on this research study," says Roma Chilengi, MD, chief scientific officer at the Centre for Infectious Disease Research in Zambia. "They understand the importance of this vaccine for themselves and their children.”

Based on what they learn from this study, the Centre for Infectious Disease Research in Zambia plans to assist Zambia's national cholera prevention, control and elimination program in deploying the oral cholera vaccine to other fishing camps in the country.

This spring, photographer Karen Kasmauski traveled to Zambia for DOVE to document the lives of those involved in the study — and to demonstrate how challenging it is for the fishermen and their families to drink and bathe in clean water.

Friday Mwape, 47, is one of those fishermen. He is also a volunteer who helps recruit people for the vaccine study.

Two of his sons, Frances and Lenard (pictured above), became sick with cholera in 2016 while fishing deep in the swamp. They both recovered because their father recognized the symptoms, reacted quickly and rowed them to safety while calling ahead to secure appropriate treatment.

He and other volunteers spread the word about the value of the oral cholera vaccine as they go door-to-door to recruit volunteers for the study.

They also travel through the swamp and visit the fishermen who live in the floating villages. Mwape tries to educate fellow fishermen about the importance of drinking safe water and the signs and symptoms of cholera.

They also discuss the cholera vaccine study. Here, Mwape helps a fisherman as he smokes his catch.

Mwiya Muakasa, 23, (left) sells his fish at the Waya port. He got the vaccine in 2016 after many of his fellow fishermen were sickened by cholera that year. He's a true believer in the vaccine.

According to the most recent estimates, there are more than 1.3 billion people at risk of cholera globally — of which, 2.86 million will contract cholera and 95,000 will die annually. The World Health Organization says that 159 million people around the world drink untreated water.

Cholera outbreaks have occurred annually in Zambia since 1977, with the exception of a four-year period without any reported cases from 2012 to 2015.

In Zambia, roughly 41 percent of the population lacks proper sanitation facilities. Twenty-five percent of those in rural areas do not have latrines and 70 percent of rural areas lack hand-washing facilities. The area that includes the Lukanga swamp is considered one of several locations in Zambia at increased risk of cholera outbreaks due to poor water, sanitation and hygiene conditions.

"Our goal at the DOVE project is to ensure that those at risk of cholera benefit from receiving the vaccine in an appropriate and effective manner," says David Sack, MD, who directs the DOVE project at Johns Hopkins. "This study will help us better understand effective dosing schedules for vaccine, which will prevent illnesses and deaths, especially for vulnerable populations like those living in the Lukanga swamp where access to water, sanitation and hygiene pose a grave challenge.”

All photos taken by Karen Kasmauski.

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