"Action is needed, not tomorrow, but really now," said Yap Boum of the Africa Centres for Disease Control and Prevention.
He's talking about a disease that has been around for centuries — cholera — and is rearing its head again in Africa. Over the past three years, cases have more than doubled, with over 230,000 cases and nearly 5,000 deaths so far this year on the continent. Those cases are spread across 23 countries, up from 15 affected countries in 2022, according to Africa CDC.
It's a disease that is easily treatable — yet deadly. It can kill someone in a matter of hours if good medical care is not provided promptly.
The rising numbers brought African leaders to Lusaka, Zambia, where last week they announced an emergency plan and presidential task force to combat the severe diarrheal infection. The new plan is a joint effort between Africa CDC and the World Health Organization.
WHO, in a situation report on cholera published last week, wrote that the situation "continues to deteriorate, driven by conflict and poverty." It said cholera is "resurging in a number of countries, including some that had not reported substantial case numbers in years, like Chad and the Republic of Congo." Particularly worrisome is that in half a dozen countries over 1% of patients are dying of cholera, "indicating serious gaps in case management and delayed access to care," according to the report.
The infection comes from consuming water or food contaminated by the bacterium Vibrio cholerae. Boum says an important part of the new initiative is that it is happening at the presidential level. That allows coordination across countries, as well as across multiple ministries within a country, such as those involved in water infrastructure.
"The actual driver, which is the access to clean water, is not the mandate of the Ministry of Health. So what is changing now is to bring the issue of cholera at the highest level, at the presidential level," Boum says.
With an estimated budget of $231 million, the emergency plan is focused on the next six months. This includes over 350 cholera treatment centers and hundreds of outpatient treatment locations. An estimated 10 million oral cholera vaccine doses will be needed, and the costs associated with the vaccine will be covered by donations. Boum said one of the mandates of the task force is to mobilize resources for this effort.
The plan's long-term goal is to eliminate cholera as a major public health issue by 2030 — a lofty aim for an ancient infection. Here is what you need to know about this old scourge that's still causing suffering today.
Ancient history
Cholera's origins are in India.
"It's been in the Ganges delta from time immemorial," says Dr. David Sack, a professor of international health at the Johns Hopkins Bloomberg School of Public Health, who's spent much of his career studying the disease. Cholera began spreading from India throughout the West in the early 1800s with more global trade and travel by ships, he explains. Soon there were cases cropping up all the way from Russia and Western Europe to U.S. cities, including Baltimore, New York and Philadelphia.
"It was a disease that affected large parts of the world," Sack says. With a fatality rate of about 50% if untreated, it killed millions of people as it spread across the globe.
"At that time, we didn't know what caused it," he says. "We didn't know how to treat it."
Theories about the cause of the illness were plentiful. The leading suspect was the foul air rising from sewers and piles of rotting trash in cities; poison from the soil was another possible culprit. Others looked higher up for a cause: Some faith leaders said it was retribution by God for sinful behavior.
Nearly all of the theories had a common thread, though. There appeared to be a link between cholera and overcrowded urban areas.
Finally, in the 1850s, an English doctor named John Snow became a legend of public health for figuring out that an outbreak in the Soho neighborhood of London was linked to a single drinking water source. Snow is credited with stopping the raging outbreak, which claimed 10,000 lives across London, by removing the handle from the Broad Street water pump.
Snow argued correctly that water contaminated with sewage was spreading the illness from one resident to another. But he still didn't know exactly what the water was contaminated with; at the time, the pathogen that caused cholera hadn't yet been discovered. He theorized that it might be tiny parasites or germs or some "poison" able to reproduce in the water.
Around the same time, Italian scientist Filippo Pacini identified the bacteria that cause cholera. But his discovery wouldn't be widely accepted for decades — and in the meantime, millions more died.
Fast killer
One thing that makes cholera notorious is its speed. The severe gastrointestinal disease can trigger so much diarrhea and vomiting that patients can rapidly become dehydrated. They can lose so much fluid that their internal organs shut down. This can happen over the course of days or just hours.
According to the World Health Organization, there are 1.3 million to 4 million cases and between 21,000 and 143,000 deaths from cholera each year.
Cases crop up throughout the world, particularly when a crisis or conflict strikes and clean drinking water is not available. And Africa has been particularly hard hit, currently accounting for 82% of global cases and nearly 94% of cholera-related deaths, according to Africa CDC. Cholera often spreads when someone ingests water or food that has been contaminated by the bacteria, which can enter the water from the diarrhea of someone who is infected.
Climate and conflict
There are two main types of cholera outbreaks: those that circulate within countries where outbreaks happen regularly and those that begin spiraling out of control during a crisis, such as a conflict or natural disaster like a flood or an earthquake.
In war zones like Ukraine, the breakdown of water, sanitation and health infrastructure means that the introduction of cholera can spread rapidly — and disastrously.
"As those infrastructure systems crumble in conflict, we can have sewage contamination of our water supply, and then our water supply can be a vehicle to transmit cholera," says Daniele Lantagne, a research professor at the Feinstein International Center at Tufts University.
During its ongoing civil war, for example, Yemen has had the worst cholera outbreak in recorded history with more than 2.5 million cases and around 4,000 deaths, according to the United Nations' International Organization for Migration. In Chad, the cholera outbreak is driven by the conflict in neighboring Sudan. "You have the mass refugee influx, which leads to overcrowding [in] the camp with unsafe water and sanitation," says Boum. "Whether we are in Ethiopia, in Sudan, in Chad, you always see how the humanitarian crisis is fueling those cholera outbreaks. There is no health without peace."
Meanwhile, natural disasters — which can affect clean water supply — are becoming more common due to climate change. Floods, for example, pollute water, while drought dries up safe drinking water sources.
That puts people fleeing areas destroyed by climate disasters at higher risk of exposure to cholera. "Any time you get people moving around, and people having to use water that is not their normal water supply, there's likely to be a risk," says Sack, the professor of international health at Johns Hopkins.. People on the move may end up drinking contaminated water from rivers or other water sources.
And in places where cholera is newly emerging or remerging, people have little to no immunity from prior cases or vaccination.
Souped-up sugar water
"The good news about cholera is that treatment is actually very simple: It's rehydration," Lantagne says.
Cholera is a treatable disease — as long as the patient gets medical attention quickly.
"A patient with cholera should never die," Sack says. "If they get to a treatment center in time, if they still have a breath, we can save their life."
Treatment consists of simply keeping the person hydrated. If they are capable of drinking, they can be treated with oral rehydration fluids — basically souped-up sugar water, like Pedialyte. This strategy works in about 80% of cholera cases. In more severe cases, the patient may need to be given fluids intravenously alongside antibiotics.
If cholera is treated quickly — within hours, before a patient's health declines — fewer than 1% of patients die.
Cholera is also fairly easy to identify. Patients have distinctive stool that is yellowish or whitish — kind of like the color of water that rice is cooked in.
And there are rapid tests that can check for suspected cases in individuals even before a laboratory confirms an outbreak.
There are also three vaccines that can be administered in areas where cholera occurs regularly or when an epidemic begins to take root. Between 1997 and 2012 just 1.5 million doses of cholera vaccines were used worldwide, according to WHO. In 2017, WHO says that number jumped to over 10 million doses. And in 2023, some 35 million doses were used, says Gavi, the Vaccine Alliance.
Yet the vaccine supply is sometimes inadequate, mainly because it has not been a funding priority for other countries. "We don't have enough [vaccines] for every place," Sack says. And it is difficult to venture into conflict zones, like the one in Ukraine, to vaccinate people.
In 2013, however, Gavi established a cholera vaccine stockpile. Any country can request to use these reserves if it's experiencing a cholera outbreak. "Cholera is certainly the stockpile that's used the most," says Allyson Russell, the senior program manager for outbreaks and global health security at Gavi. This year, as of July, she says, "we've sent 30 million doses of cholera emergency vaccines to 12 countries."
The vaccines are given orally, are easy to administer and cost less than $5 a dose to produce and deliver, according to Africa CDC. That means that with enough resources, everyone at risk could be vaccinated. The challenge of providing people with safe water and good sanitation is far more costly but also key to preventing outbreaks. Without it, cholera persists even after an epidemic begins to slow.
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