Multi-Country Outbreak of Cholera: WHO Releases 7 Months Report

According to WHO, the Eastern Mediterranean Region recorded the highest numbers, followed by the African Region, the South-East Asia Region, the Region of the Americas, and the European Region.

The cholera response is facing significant challenges due to a severe shortage of Oral Cholera Vaccines (OCV), with demand far exceeding supply. Since January 2023, 18 countries have requested 105 million doses, nearly double the 55 million doses produced during this period.

In January 2023, the World Health Organization classified the global cholera resurgence as a grade 3 emergency, its highest level for emergencies.

Given the increasing number of outbreaks, their geographic spread, and the ongoing vaccine and resource shortages, WHO continues to assess the global risk as very high, maintaining the grade 3 emergency status.

The WHO said warming temperatures that allow the cholera bacteria to live longer, has worsened outbreaks and led to the highest death rates in a decade.

Data as of 28 July 2024
• In July 2024 (epidemiological weeks 27 to 30), a total of 51 982 new cholera cases were reported from 17 countries, territories, areas (hereafter countries) across four WHO regions, showing a 15% increase from the previous month. The Eastern Mediterranean Region registered the highest number of cases, followed by the African Region, the South-East Asia Region, and the European Region. The period also saw 223 cholera-related deaths globally, highlighting a 34% increase from the previous month. Around the same time last year, 75 214 cases and 166 cholera-related deaths were reported from 22 countries. Cases and deaths reported over this period in 2024 are 31% lower and 34% higher, respectively than those reported over the same period last year.
• For the latest data, please refer to WHO’s Global Cholera and Acute Watery Diarrhoea (AWD) Dashboard.
• Since late July 2024, Nepal reported new clusters of cholera cases in several districts across the country, including 20 cases from Lalitpur, Kathmandu, and Kailai districts.
• From 1 January 2024 to 28 July 2024, a cumulative total of 307 433 cholera cases and 2326 deaths were reported from 26 countries across five WHO regions, with the Eastern Mediterranean Region recording the highest numbers, followed by the African Region, the South-East Asia Region, the Region of the Americas, and the European Region. No outbreaks were reported in the Western Pacific Region during this time.
• The cholera response continues to be affected by a critical shortage of Oral Cholera Vaccines (OCV) as demand continues to outpace supply, with 105 million doses requested by 18 countries since January 2023, nearly double the 55 million doses produced in this period.
• WHO classified the global resurgence of cholera as a grade 3 emergency in January 2023, the highest internal level for emergencies in WHO. Based on the number of outbreaks and their geographic expansion, alongside the shortage of vaccines and other resources, WHO continues to assess the risk at the global level as very high and the event remains classified as a grade 3 emergency.
• WHO collaborates with global, regional, and country partners to support Member States in outbreak response.
• The dynamics of cholera outbreaks are increasingly complex due to factors that transcend national boundaries, such as population mobility, natural disasters, and climate change. The risk of transnational transmission is often heightened by porous borders with numerous unofficial entry points, inadequate disease surveillance at border areas, and limited awareness in cholera-affected communities. To address these challenges, countries must prioritize cross-border collaboration by establishing real-time data sharing mechanisms, harmonizing surveillance systems, pooling resources, and implementing joint preparedness and response interventions.

2. Global epidemiological update
In July 2024 (epidemiological weeks 27 to 30), a total of 51 982 new cholera cases were reported from 17 countries across four WHO regions, marking a 15% increase from the previous month. The Eastern Mediterranean Region (43 508 cases; six countries) reported the highest number of cases, followed by the African Region (7241 cases; seven countries), the South-East Asia Region (1223 cases; three countries), the European Region (10 cases; one country). In the same period, 223 cholera-related deaths were registered globally, representing a 34% increase compared to the previous month. The highest number of fatalities was recorded in the African Region (162 deaths; five countries), followed by the Eastern Mediterranean Region (60 deaths; four countries) and the South-East Asia Region (one death; one country). During this period, no deaths were reported in the European region.

From 1 January to 28 July 2024, a cumulative total of 307 433 cholera cases and 2326 deaths were reported globally across five WHO regions. The region with the highest reported case count was the Eastern Mediterranean Region (188 321 cases; six countries), followed by the African Region (111 168 cases; 14 countries), the South-East Asia Region (5052 cases; four countries), the Region of the Americas (2672 cases; one country), and the European Region (220 cases; one country). During this period, cholera deaths were reported in the African Region (1899 deaths), the Eastern Mediterranean Region (403 deaths), the Region of the Americas (13 deaths), the South-East Asia Region (nine deaths), and the European Region (two deaths). Notably, the Western Pacific Region did not report any cholera
outbreaks. The data presented here should be interpreted cautiously due to potential reporting delays. This may affect the\ timeliness of reports, and consequently, the presented figures might not accurately represent the true burden of cholera. The diversity of surveillance systems, case definitions, and laboratory capacities among countries means that statistics on cholera cases and deaths are not directly comparable. Additionally, the global case fatality rate (CFR) for cholera warrants a prudent examination as it is heavily influenced by variations in surveillance methodologies. In this document, the term ‘cholera cases’ encompasses both suspected and confirmed cases, unless specified otherwise for specific countries. The data within this report are subject to potential retrospective adjustments as more accurate information becomes available.

African Region
In July 2024, the African Region reported 7241 new cholera cases across seven countries, marking a 9% decrease compared with the case numbers reported in the previous month. During this period, the highest numbers of cases were reported from Nigeria (3198 cases), Ethiopia (2086 cases), and the Democratic Republic of the Congo (1246 cases). Additionally, there were 162 cholera-related deaths, a 76% increase compared with the previous month. The highest numbers of deaths were reported from Nigeria (102 deaths), Ethiopia (43 deaths), and the United Republic of Tanzania (11 deaths).
From 1 January to 28 July 2024, a total of 111 168 cholera cases were reported across 14 countries in the African Region. During this period, the highest numbers of cases were reported from Ethiopia (21 254 cases), the Democratic Republic of the Congo (20 659 cases), and Zambia (20 219 cases). During the same period, a total of 1899 deaths were reported from 12 countries, with the highest numbers recorded in Zambia (637 deaths), Zimbabwe (399 deaths), and the Democratic Republic of the Congo (274 deaths).

Eastern Mediterranean Region
In July 2024, the Eastern Mediterranean Region reported 43 508 new cholera cases across six countries, marking a 17% increase compared with the case numbers reported in the previous month. During this period, the highest numbers of cases were reported from Afghanistan (24 951 cases), Yemen (8929 cases), and Pakistan (7932 cases). Additionally, there were 60 cholera-related deaths, a 19% decrease compared with the previous month. The highest numbers of deaths were reported from Yemen (30 deaths), Sudan (15 deaths), and Afghanistan (10 deaths).

From 1 January to 28 July 2024, a total of 188 321 cholera cases were reported across six countries in the Eastern Mediterranean Region. During this period, the highest numbers of cases were reported from Afghanistan (95 301 cases), Pakistan (38 636 cases) and Yemen (24 308 cases). During the same period, a total of 403 deaths were reported from four countries, with the highest numbers recorded in Yemen (140 deaths), Somalia (137 deaths), and Sudan (78 deaths).

European Region
In July 2024, the European Region reported 10 new cholera cases and no new deaths in the French overseas department of Mayotte in the Indian Ocean, marking an 88% decrease compared with the previous month. From 1 January to 28 July 2024, a total of 220 cholera cases and two deaths were reported from Mayotte.

Region of the Americas
In July 2024, the Region of the Americas reported no new cholera cases. From January to July 2024, Haiti documented 2672 cholera cases and 13 deaths.

South-East Asia Region
In July 2024, the South-East Asia Region reported 1223 new cholera and AWD cases from three countries, marking a significant increase compared with the case numbers reported in the previous month. During this period, cases were reported from Myanmar (1141 cases), Bangladesh (62 cases), and Nepal (20 cases). Additionally, one cholera-related death was reported from Myanmar.

From 1 January to 28 July 2024, a total of 5052 cholera and AWD cases were reported across four countries in the South-East Asia Region. During this period, cases were reported from India (3805 cases), Myanmar (1141 cases), Bangladesh (86 cases), and Nepal (20 cases). During the same period, a total of nine deaths were reported from two countries: India (eight deaths) and Myanmar (one death).

Western Pacific Region
From 1 January 2024 to 28 July 2024, the Western Pacific Region reported no new cholera cases or deaths.

Myanmar
On 7 July 2024, the Ministry of Health of the Republic of the Union of Myanmar announced in a press release that an AWD outbreak had begun in the Yangon region in early June. Since late June, severe diarrhoea cases have been admitted to hospitals in some townships in the eastern district of Yangon, including Thaketa Township. As of 22 July, a total of 1141 AWD cases have been hospitalized, with 139 severe cases reported, including one death.

Nigeria
In July 2024, Nigeria reported 3198 new cholera cases and 102 associated deaths with a CFR of 3.2%, marking a 192% increase in cases and a 149% increase in deaths compared with the previous month. Since January 2024, the country reported a total of 5300 cases and 165 deaths with a CFR of 3.1%. While the overall epidemiological situation is improving, the situation remains concerning especially in Lagos state, which accounts for over 60% of the total cases reported this year.

Democratic Republic of the Congo
In July 2024, the Democratic Republic of the Congo reported 1246 new cholera cases and four associated deaths with a CFR of 0.3%, marking a 32% decrease in cases and a 43% decrease in deaths compared with the numbers reported in the previous month. Since January 2024, the country reported a total of 20 659 cases and 274 deaths with a CFR of 1.3%.

Horn of Africa
Ethiopia
In July 2024, Ethiopia reported 2086 new cholera cases and 43 associated deaths with a CFR of 2.1%, marking a 26% increase in cases and a 258% increase in deaths compared with the numbers reported in the previous month. Since January 2024, the country reported a total of 21 254 cases and 182 deaths with a CFR of 0.9%.

Somalia
In July 2024, Somalia reported 1490 new cholera cases and five associated deaths with a CFR of 0.3%, marking a 23% decrease in cases and a 50% decrease in deaths compared with the numbers reported in the previous month. Since January 2024, the country reported a total of 17 246 cases and 137 deaths with a CFR of 0.8%.

WHO is working with partners at global, regional, and country level to support Member States in the following cholera outbreak response activities:

Coordination
• In response to the needs in countries and with support from key partners, experts were deployed through the Global Outbreak Alert and Response Network (GOARN), Standby Partners (SBP), and Emergency Medical Teams (EMT) in addition to weekly information exchange on operational updates for cholera response through the GOARN Weekly Ops call forum.
• As of 28 July, 20 experts have been deployed to Malawi, Mozambique, Kenya, Lebanon, Haiti, Sudan, Zambia, Comoros and Yemen through GOARN to support the cholera response, specifically Health Operations, Case Management, Social anthropology and Epidemiology/Surveillance, Health Cholera Coordinator and Partner Coordination
• As of 28 July, 18 experts have been deployed (for a duration of 3 to 6 months each) to eight countries (Malawi, Mozambique, Cameroon, Haiti, Turkey, Ethiopia, Zambia, Comoros and Myanmar) through the Standby Partners to support the cholera response for the functions of Information management (IMO), Partner/Cluster Coordinator, Preventing and Responding to Sexual Exploitation, Abuse and Harassment (PRSEAH), Infection Prevention and Control (IPC)/Water Sanitation and Hygiene (WASH), Risk Communication and Community Engagement (RCCE) and Logistics (OSL).

Public health surveillance
• The Global Task Force on Cholera Control (GTFCC) has published revised guidance on public health
surveillance for cholera, which comes with accompanying tools. In August 2024, this material was released in Arabic, French, and Portuguese to supplement English.
• Countries are encouraged to periodically self-assess their cholera surveillance system and strategies using the GTFCC method to assess cholera surveillance in order to identify priority activities to strengthen their cholera surveillance system/strategies towards meeting the standards set in the GTFCC revised guidance on public health surveillance for cholera.
• GTFCC technical recommendations on standard data and metadata sets for cholera reporting at regional and global levels are being promoted. A template is available for cholera reporting at regional and global levels.
• Support in data management and analysis is being provided to countries and regions on a case-by-case basis.
• Coordination efforts are underway with countries, regions, and partners to strengthen cholera surveillance.
• Identification of Priority Areas for Multisectoral Interventions (PAMIs) makes it possible to maximize the impact of control strategies and direct resources to the most affected or vulnerable areas. GTFCC guidance for the identification of PAMIs for cholera control is being disseminated and promoted (in English, Arabic, French, and Portuguese). This guidance aims to maximize the use of surveillance data for cholera-affected countries in the development or revision of a National Cholera Plan for cholera control.

Health Operations
• The GTFCC Cholera Outbreak Response Field Manual is now available in Arabic: Link
• A package describing the core activities and functions of each sub-pillar to support the set-up of cholera Incident Management Teams (IMTs) is being developed.

Laboratory
• Technical support and assistance in the development of laboratory strengthening plans for countries are being provided on a case-by-case basis.
• Support was provided to identify laboratory diagnostic supply needs and deployment of laboratory supplies in countries with acute and active outbreaks. Prepositioning of supplies for preparedness and readiness in key countries is ongoing.
• Countries are being supported in defining and implementing testing strategies during outbreaks.
• Collaboration with Gavi continues to support the procurement of cholera RDTs for Gavi-eligible countries, enhancing cholera surveillance and outbreak monitoring.
• Training materials for cholera diagnostics continue to be developed.
Vaccination
• Twelve new requests were received in 2024 from Comoros, Ethiopia (2), Kenya, Mozambique, Myanmar, Nigeria, Somalia, Sudan, Yemen, Zambia, and Zimbabwe, collectively seeking 32 million doses. Nine were approved, one was not approved, one was cancelled, and one is pending decision from the International Coordinating Group (ICG) on Vaccine Provision. Two additional countries are considering submitting requests.
• Since the start of 2024, seven countries (Comoros, Ethiopia, Mozambique, Somalia, Sudan, Zambia, and Zimbabwe) have carried out ten reactive vaccination campaigns in response to cholera outbreaks, targeting a total of 11 million people. Given the current context of outbreaks and limited vaccine availability, only single dose vaccination courses have been validated and utilized in these reactive campaigns.
• The constrained supply of OCVs is severely impacting the capacity to carry out preventive vaccination
campaigns. The limited global stockpile of OCVs underscores the need for increased production and strategic stockpile management to ensure that both reactive and preventive needs are adequately met.
Case management, Infection Prevention and Control (IPC) & Water, Sanitation and Hygiene (WASH)
• As part of a support project by the U.S. Centers for Disease Control and Prevention, training on WASH/IPC response, focusing on the implementation of water quality monitoring, has been conducted in Niger.
• The development of a WASH toolkit for managing WASH/IPC response is underway. This tool will guide country offices in coordinating and operationalizing their activities.
• Support continues to be provided on IPC and WASH to affected countries, including Nigeria and Ethiopia.
• The GTFCC modular case management training is being completed.
• Technical support includes the sharing of the recently completed job aids/posters and indicators (Nigeria, Myanmar, Somalia).

Risk communication and community engagement (RCCE)
• Coordination efforts are continuing with regions and partners, with cholera resources available.
• Response checklist and key messages are under revision.
• RCCE technical and surge support continues based on country needs and demands.
• An RCCE readiness and response toolkit for cholera is under development. The ultimate goal of this toolkit is to provide RCCE focal points and practitioners with a set of tools to strengthen their work to inform, engage and empower communities at risk from Cholera.

Funding
• Only $18 million, or 11% of the $163 million required, has been secured since 2023. This amount is insufficient to meet the operational needs for controlling cholera transmission and provide life-saving solutions, such as\ clean water, sanitation, rapid response teams, and medical supplies.
• Increased investments from governments, NGOs, international agencies, and donors are urgently needed.
• Enhanced financial support and innovative funding mechanisms are essential to bridge this gap and ensure a robust cholera response.

Key challenges
The geographical spread and global surge in cases is due to and has resulted in numerous challenges:
• Exacerbation of cholera outbreaks due to natural disasters and climatic effects.
• Data quality and reporting, including issues with reporting consistency and insufficient disaggregation of data for vulnerable groups, especially for children under 5 years of age.
• Insufficient OCV stocks to respond to all concurrent cholera outbreaks, resulting in the suspension of
preventive campaigns and a transition from a two-dose to a one-dose strategy. Between January and May 2024, the vaccine stockpile was entirely depleted.
• Exhausted national cholera response capacities and overall overstretched emergency response capacity due to numerous parallel large-scale and high-risk outbreaks and other emergencies affecting public health.
• Limited experienced cholera response staff available for deployments to support national emergency
responses.
• Increased risk of cross-border cholera transmission due to porous borders with numerous unofficial points of entry points, inadequate surveillance at border areas, and limited cholera awareness in affected communities.
• Inadequate financial resources to respond in a timely and effective manner across all levels.
• A lack of resources for prevention, readiness, and preparedness activities.
• Lack of technical capacity required for effective readiness to respond in Member States.

Next steps
To address the challenges identified above, WHO, UNICEF, IFRC and partners will continue to work together.
• Cholera scenario planning/prioritization will continue to be updated, considering the impact of severe climatic events at the global, regional, and national levels.
• WHO will continue to advocate for investment in cholera preparedness and response, highlighting that long- term investment is critical for a sustainable solution, while emphasizing that immediate investment is needed for rapid emergency response to the current surge in cases.
• WHO and UNICEF will continue to work with partners to streamline the supply of essential cholera materials, including vaccines, ensuring maximum availability based on the prioritization of needs.
• WHO and partners, including the GTFCC, will continue to support Ministries of Health and implementing partners with the latest available information and material to enable prevention and response activities in the current constrained environment.
• WHO, UNICEF, and partners will continue to work together to maintain focus on the cholera emergency, to mobilize resources and lobby for long-term solutions to reduce the cholera burden. In addition, WHO, UNICEF and other partners will continue to work together to streamline response efforts and maximize limited resources.

Annex 1. Data, table, and figure notes
Caution must be taken when interpreting all data presented. Differences are to be expected between information products published by WHO, national public health authorities, and other sources using different inclusion criteria and different data cut-off times. While steps are taken to ensure accuracy and reliability, all data are subject to continuous verification and change. Case detection, definitions, testing strategies, reporting practice, and lag times differ between countries/territories/areas. These factors, amongst others, influence the counts presented, with variable underestimation of the true case and death counts, and variable delays to reflecting these data at the global level.

‘Countries’ may refer to countries, territories, areas, or other jurisdictions of similar status. The designations employed, and the presentation of these materials do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Countries, territories, and areas are arranged under the administering WHO region. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted; the names of proprietary products are distinguished by initial capital letters.

Technical guidance and other resources
• Cholera fact sheet
• Ending Cholera, A Global Roadmap To 2030
• Global cholera strategic preparedness, readiness, and response plan 2023/24
• WHO’s Call for urgent and collective action to fight cholera
• Disease outbreak news Cholera – Democratic Republic of the Congo
• Disease outbreak news Cholera – Haiti
• Disease outbreak news Cholera – Malawi
• Disease outbreak news Cholera – Mozambique
• Disease outbreak news Cholera-Global situation
• Global Task Force on Cholera Control (GTFCC)
• GTFCC fixed ORP interim guidance and planning
• Public health surveillance for cholera, Guidance document, 2024
• AFRO Weekly outbreaks and emergency bulletin
• WHO AFRO Cholera Dashboard
• Cholera outbreak in Hispaniola 2022 – Situation Report
• Cholera upsurge (2021-present) web page