Antimicrobial Resistance Risks of Cholera Prophylaxis for United Nations Peacekeepers

Abstract

More than 5 years after a United Nations peacekeeping battalion introduced cholera to Haiti, over 150,000 peacekeepers continue to be deployed annually from countries where cholera is endemic. The United Nations has thus far declined to provide antimicrobial chemoprophylaxis to peacekeepers, a policy based largely on concerns that the risks of drug resistance generation and spread would outweigh the potential benefits of preventing future cholera importations. In this study, we sought to better understand the relative benefits and risks of cholera chemoprophylaxis for peacekeepers in terms of antibiotic resistance. Using a stochastic model to quantify the potential impact of chemoprophylaxis on importation and transmission of drug-resistant and drug-sensitive Vibrio cholerae, we found that chemoprophylaxis would decrease the probability of cholera importation but would increase the expected number of drug-resistant infections if an importation event were to occur. Despite this potential increase, we found that at least 10 drug-sensitive infections would likely be averted per excess drug-resistant infection under a wide range of assumptions about the underlying prevalence of drug resistance and risk of acquired resistance. Given these findings, policymakers should reconsider whether the potential resistance risks of providing antimicrobial chemoprophylaxis to peacekeepers are sufficient to outweigh the anticipated benefits.

UN peacekeeper health and risk factors --- a systematic scoping review

“…Two studies focused on exploring Chinese peacekeepers’ knowledge on AIDS, one on the use of knowledge, belief and behavior questionnaire recommended by WHO among 528 peacekeepers in Liberia before and after health education [ 66 ], and another on 99.2% (264/266) of peacekeepers’ understanding AIDS transmission routes in Sudan [ 67 ]. Malaria and cholera: Four studies reported the use of chemoprophylaxis agianst cholera and malaria, anti-malarial therapy, screening and vaccination [ 76 – 78 , 81 ]. Seven studies reported imported cases and high rates of malaria transmission and intended to characterize the potential causes of malaria outbreak among peacekeepers [ 70 , 76 , 79 , 80 , 82 , 83 ].…”

“…Malaria and cholera: Four studies reported the use of chemoprophylaxis agianst cholera and malaria, anti-malarial therapy, screening and vaccination [ 76 – 78 , 81 ]. Seven studies reported imported cases and high rates of malaria transmission and intended to characterize the potential causes of malaria outbreak among peacekeepers [ 70 , 76 , 79 , 80 , 82 , 83 ].…”

“…A review by Shigemyra et al also identified the association between UN peacekeepers’ exposure to multiple events and the further development of their health problems after deployment [ 155 ]. Drabick and Kunkel listed examples of UN Peacekeepers contributing to disease spreading, such as Hepatitis E Infection and the Cholera in Haiti [ 81 , 85 ]. The health problems of UN peacekeepers are complicated, and whose impacts are cross-border.…”

“… African Region: Nigeria West Africa Questionnaire Situationally focused individual HIV intervention Multination Multination Prevalence comparison HIV prevalence of the peacekeeping mission is higher than that of the host country. Malaria and cholera Hu et al 2005 [ 64 ], Jeremy et al 2005 [ 70 ], Jin et al 2008 [ 67 ], Xie et al 2009 [ 71 ], Wang et al 2011 [ 72 ], Wei et al 2011 [ 73 ], Ma et al 2011 [ 74 ], Sun et al 2012 [ 75 ], Juliao et al 2013 [ 76 ], Kapoor et al 2013 [ 77 ], Lewnard et al 2015 [ 78 ], Fernando et al 2016 [ 79 ], He et al 2017 [ 80 ], Kunkel et al 2017 [ 81 ], Fernando et al 2017 [ 79 ], Qi et al 2018 [ 82 ], Guerra et al 2019 [ 83 ], Li et al 2021 [ 84 ] Western Pacific Region: China Sudan, South Sudan, Liberia, The Democratic Republic of Congo Medical report, Retrospective study, Questionnaire The provision of care for patients with malaria and cholera. South-East Asia Region: Sri Lanka, Nepal The Central African Republic, Haiti, Multination Questionnaire, Interviews, Stochastic modeling 30.8% of peacekeepers (37/120) had 44 symptomatic episodes of malaria during deployment.…”

Implementation of targeted cholera response activities, Cameroon

“…Full packages of case-area targeted interventions include antibiotics used for prophylaxis of close household contacts. 10 , 30 However, due to concerns about emergence of resistant V. cholerae strains, 31 , 32 the Global Task Force on Cholera Control only recommends selective antibiotic chemoprophylaxis for closed populations at high risk of infection (such as prisons) and not community-wide chemoprophylaxis. 22 For these reasons, in our settings, chemoprophylaxis was done in the central prison and reserved for close contacts in the primary households who had not previously received a dose of oral cholera vaccine.…”