Globally, disease outbreaks have more than tripled since 1980, with 1307 epidemic events between 2011 and 2017. Cholera was the biggest contributor to this, with 308 events. Since mid-2021, the global situation has further deteriorated with an acute upsurge of cholera cases, which has put one billion people in 43 countries at risk, according to the World Health Organization.
Africa continues to bear a disproportionately high burden of the cholera outbreaks, with between 40 million and 80 million people on the continent living in cholera hotspots. Africa is witnessing an exponential rise in cholera cases amid a global surge. Cases recorded on the continent in the first month of 2023 alone have already risen by over 30% of the total caseload reached in the whole of 2022.
If the current fast-rising trend continues, it could surpass the number of cases recorded in 2021, the worst year for cholera in Africa in nearly a decade. Average case fatality ratio is currently almost at 3%, above the 2.3% reached in 2022, and far exceeding the acceptable level of below 1%. There is therefore an urgent need for concerted efforts from African governments and all relevant stakeholders to implement effective mitigation strategies that will reduce its spread and impact.
Driving factors of the cholera epidemic in Africa
Cholera is an acute diarrheal infection caused by the ingestion of food or water contaminated with the bacterium Vibrio cholerae. When severe, it is characterised by extreme watery diarrhoea and potentially fatal dehydration. Despite being easily treatable with rehydration solution, cholera remains a global health threat due to its high morbidity and mortality in vulnerable populations without access to adequate health care.
Major factors driving the cholera epidemic in Africa include poverty, extreme climate change, poor access to safe drinking water, sanitation and hygiene, political conflicts and insecurity, and limited access to healthcare, amongst others. Deep and widespread poverty across Africa limits the effectiveness and sustainability of public health interventions to improve water and sanitation services.
Climate change is leading to severe drought in some areas in Africa, and floods in others, resulting in increased population displacement and reduced access to clean water. In the horn of Africa, countries like Ethiopia, Kenya, and Somalia are experiencing severe drought which is driving population movements and increasing the risk of spread of cholera, as well as high levels of malnutrition, which increase the risk of severe outcomes of cholera in the region.
In the Democratic Republic of Congo (DRC), political conflict in the province of North Kivu led to an increased influx of internally displaced people (IDPs) to camps. The lack of access to water and sanitation in the camps fuelled the ongoing cholera outbreak. In addition, multiple graded emergencies in Africa have led to overstretched financial resources and human capacity due to other public health emergencies, such as COVID-19, mpox, and malnutrition. There is also limited availability of vaccines, medicines and testing kits for cholera.
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Mitigation strategies to curb the rising cholera epidemic in Africa
Effective control of the cholera epidemic in Africa relies on implementing comprehensive measures including enhanced epidemiological and laboratory surveillance to detect, confirm and quickly respond to outbreaks, improving access to treatment, vaccines, safe water, and basic sanitation, as well as effecting behavioural change and better hygiene practices among communities. Bloom Public Health therefore recommends the following mitigation strategies:
1. Increased investment to finance public health WASH interventions: Developing safe water sources and sanitation would dramatically reduce the number of people contracting cholera. However, a recent report stated that achieving universal safe drinking water, sanitation, and hygiene in sub-Saharan Africa would cost $35 billion per annum. Efforts to achieve sustainable transformation are therefore expensive and require a pooled investment from various stakeholders.
2. Improved disease surveillance and vaccination: African governments need to strengthen surveillance, including strengthening diagnostic algorithms, use of rapid diagnostic tests, collecting and transporting of samples, and strengthening laboratory capacity to culture V. cholerae. Also, target populations/hotspots for vaccination should be identified and vaccine requested for through the International Coordinating Group (ICG) on Vaccine Provision mechanism, in the context of acutely limited supply.
3. Strengthening access and improving healthcare quality: This includes setting up dedicated healthcare facilities such as Cholera Treatment Centres (CTCs) to provide prompt administration of oral rehydration solution or intravenous fluids and management of complications. This requires a skilled workforce and clear clinical pathways, ensured through training for health workers and provision of technical guidance.
4. Establishment of community-based and publicly supported programmes that promote behavioural change and education is crucial to improving public adoption of safe and hygienic practices. Communities also need to be engaged to ensure rapid hydration support for people with suspected cholera and rapid care seeking behaviour.
In conclusion, every death due to cholera is preventable, and the disease is easily treatable. Africa must act now to reduce the spread and impact of this cholera epidemic by making major investments in sustainable water, sanitation, hygiene services, improved disease surveillance, and stronger health systems. Fortunately, the return on these investments will be immense, with significant progress in sustainably controlling and ending cholera.
