Disease Outbreaks

Emergency Response: Mapping Cholera Hot Spots in Africa

The map above shows concentrations of cholera in sub-Saharan Africa. (Map by Andrew Schroeder/Direct Relief, with data sourced from Justin Lessler, et al, The Lancet)
The map above shows concentrations of cholera in sub-Saharan Africa. (Map by Andrew Schroeder/Direct Relief, with data sourced from Justin Lessler, et al, The Lancet)

Cholera originated in Asia, but now presents a global threat. This acute intestinal disease is biologically caused by exposure to the vibrio cholerae bacteria, but it’s fed socially by poor water and sanitation, limited health systems, crowding and poverty. With all these conditions present in abundance across the African continent, cholera outbreaks happen most frequently there relative to all other parts of the world. This leads in many cases to high numbers of deaths, high costs to health systems and regular social disruption.

Recent studies have shown that while cholera risks exist throughout Africa, that burden is concentrated in a limited number of very specific places, which face vastly disproportionate risks overall. Uneven distribution of the disease is both a significant problem, and an opportunity to focus efforts on cholera control more precisely than in past efforts.

As Justin Lessler and his team from Cholera Dynamics at the Johns Hopkins Bloomberg School of Public Health wrote in an article for The Lancet in March, “prioritising high-risk areas could substantially increase the efficiency of cholera control programmes.”

This year’s outbreaks are especially serious and widespread. The World Health Organization reports that 11 countries distributed across virtually all parts of Africa, from Nigeria to Somalia to Zambia, are right now in the grip of cholera outbreaks of varying size and intensity. Of the 58 total emergency health events currently being monitored in Africa, roughly 20 percent are cholera outbreaks.

Since August 2017, WHO reports 21,465 cases and 419 deaths in the cholera-affected countries.

The worst epidemics in terms of suspected case totals are happening in the Democratic Republic of Congo, Zambia, Mozambique, Kenya and Uganda.

While in every instance problems with water and sanitation lie at the base of the outbreak, DRC’s and Uganda’s outbreaks are also being driven by conflict and displacement. In DRC, all but two of the country’s 26 districts have reported cases, with fatality rates ranging from 1.5 percent to over 5 percent. The worst impacted areas are proximate to parts of the country afflicted by conflict, but in January the disease reached the capital Kinshasa, home to nearly 10 million people, many of whom live in conditions at high risk for cholera transmission.

(Chart by Andrew Schroeder/Direct Relief)

In Uganda, the epicenter of the outbreak is in Hoima district, which has seen large numbers of refugees from the Democratic Republic of Congo. So far in the northern part of the country, home to hundreds of thousands of refugees from South Sudan, no outbreaks have occurred. Nevertheless, vigilance remains high in these districts to ensure that potential outbreaks are detected and stopped early.

Of all the events currently being monitored by the World Health Organization, the highest cholera case fatality rate is in Malawi, where 3.1 percent of all suspected cases have resulted in death. In Malawi, the area of greatest concern lies in the capital, Lilongwe, where the rate of cases detections and fatalities has been persistently and unusually high for the past 15 weeks.

Direct Relief is targeting efforts in Malawi towards the UNC Project Malawi in Lilongwe, which is focusing primarily on fortifying Kumuzu Central Hospital with needed supplies and medications. A shipment of cholera control supplies arrived in Lilongwe in early March and is in the process of being deployed to frontline health centers. Two cholera treatment tents have been set up at Kumuzu Central Hospital and are daily receiving significant numbers of patients.

Direct Relief’s support in Uganda over the upcoming months will be flowing to the Real Medicines Foundation, both along the Congolese border near the epicenter of the active outbreak, and in the northern refugee camps, including Bidi Bidi, to boost epidemic preparedness in anticipation that new cases might spring up there with the return of the rainy season in April and May.

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