The challenge of Cholera today

Cholera is a severe diarrheal disease caused by the bacterium Vibrio cholerae, primarily transmitted through contaminated water and food. While it has been a deadly disease for centuries, cholera remains a significant public health concern, particularly in low-income regions where sanitation and access to clean water are limited. Although treatable, cholera continues to cause considerable mortality and morbidity worldwide, with millions of cases reported annually. Today, advances in medical treatment, sanitation, and public health efforts have mitigated some of cholera’s impacts, but the disease continues to thrive in areas facing crises such as poverty, displacement, and environmental instability. Understanding the current state of cholera is essential to appreciate its impact, the challenges in managing it, and the steps needed to reduce its global burden. Despite global improvements in water and sanitation, cholera outbreaks remain prevalent, especially in regions lacking adequate public health infrastructure. According to the World Health Organization (WHO), cholera continues to be endemic in many countries, with the majority of cases occurring in Africa and Southeast Asia. Natural disasters, armed conflict, and humanitarian crises often exacerbate the risk of cholera, as they disrupt access to safe water and sanitation facilities. In 2021 and 2022, significant outbreaks occurred in countries such as Yemen, Nigeria, and Bangladesh, often following flooding, civil unrest, or population displacement. In 2023, the WHO reported cholera cases in over 30 countries, with particularly severe outbreaks in parts of sub-Saharan Africa, underscoring the global nature of the threat. The persistence of cholera is partly due to its capacity to spread rapidly under certain conditions. In environments where hygiene is compromised, even a single case can lead to thousands, as the bacteria spread quickly through contaminated water sources. This rapid transmission makes cholera a severe threat in urban slums, refugee camps, and disaster-affected areas, where people often live in close quarters and rely on shared water sources.

Cholera’s primary symptoms are acute watery diarrhea and vomiting, which can cause rapid dehydration and shock if not treated promptly. Left untreated, cholera can be fatal within hours due to severe dehydration, but with proper treatment, mortality rates are below 1%. Treatment typically involves oral rehydration therapy (ORT), which replaces lost fluids and electrolytes, and intravenous fluids for severe cases. Antibiotics are sometimes used to reduce the duration of symptoms and bacterial shedding but are not essential for recovery in all cases. Access to treatment, however, is inconsistent across cholera-affected regions. In many areas with ongoing outbreaks, health facilities may be too few or too far away, particularly for rural populations. Additionally, lack of awareness about cholera symptoms and stigma around the disease can prevent individuals from seeking timely treatment. To mitigate these issues, the WHO and other public health organizations have promoted mobile health clinics, training for local health workers, and community outreach programs to educate people on cholera prevention and treatment. Despite these efforts, underfunded health systems continue to pose a major barrier to effective cholera management.

Preventing cholera requires improvements in water, sanitation, and hygiene (WASH) infrastructure. Safe drinking water, adequate sewage treatment, and hygiene practices, such as regular handwashing, are crucial to controlling its spread. However, millions of people worldwide lack access to basic WASH facilities, particularly in low-income countries and areas with high population density. For instance, during the 2022 cholera outbreak in Yemen, the lack of safe water sources in war-affected areas contributed significantly to the spread of the disease. In recent years, oral cholera vaccines (OCVs) have emerged as an additional tool for preventing cholera in high-risk areas. Two main OCVs, Dukoral and Shanchol, have been approved by the WHO and can provide immunity for several years. Vaccination campaigns have successfully reduced cholera incidence in some outbreak-prone regions. For example, the mass vaccination efforts in Haiti, Mozambique, and Bangladesh following major outbreaks have contributed to lowering cholera cases in these regions. However, global supply issues and the logistical challenges of distributing vaccines to remote and conflict-affected areas limit the reach of OCVs. Addressing cholera in high-risk populations also involves tackling broader social and economic factors, including poverty, inadequate health systems, and lack of infrastructure. Many cholera-affected regions face multiple public health issues, such as malnutrition, malaria, and respiratory infections, which further strain limited resources. As such, cholera management often requires a comprehensive approach that includes public health infrastructure, access to basic services, and support for health systems in fragile states.

Climate change is increasingly recognized as a factor that may exacerbate cholera outbreaks. Rising global temperatures, changing rainfall patterns, and more frequent extreme weather events such as floods and cyclones can create conditions favorable for cholera transmission. Warmer waters, for example, support the growth of Vibrio cholerae in coastal and riverine areas, increasing the risk of contamination. Additionally, flooding and cyclones can damage water and sanitation infrastructure, leading to outbreaks. In 2019, Cyclone Idai caused severe cholera outbreaks in Mozambique and Malawi, as storm damage led to widespread contamination of water sources. The WHO and other organizations are studying the relationship between climate change and cholera to better anticipate and prepare for climate-driven outbreaks. Strategies include early-warning systems that monitor environmental conditions conducive to cholera and preparedness plans that mobilize health resources in response to extreme weather events.

Although cholera remains a serious public health threat, global efforts are increasingly focused on eliminating the disease in high-risk areas through improved WASH infrastructure, vaccination, and public health awareness campaigns. The WHO launched its Global Roadmap to End Cholera by 2030, which aims to reduce cholera deaths by 90% through improved surveillance, rapid response, and investment in prevention strategies. Achieving these goals, however, will require addressing the underlying factors that make cholera endemic in certain regions, particularly poverty and inadequate infrastructure. While treatment and vaccination campaigns are essential tools, they must be complemented by long-term investments in water and sanitation systems, community health education, and climate adaptation measures. Cholera today serves as a reminder of the disparities in health infrastructure across the world. Where clean water, sanitation, and healthcare are readily available, cholera can be managed and prevented. Yet in vulnerable regions, it continues to claim lives, underscoring the need for a more equitable approach to global health. By tackling both the immediate and underlying factors of cholera, the world can move closer to eliminating this disease and creating healthier, more resilient communities worldwide.