Day: February 11, 2023

The Managing Director of the International Monetary Fund (IMF), Kristalina Georgieva, the President of the World Bank Group (WBM), David Malpass, the Director General of the United Nations Food and Agriculture Organization (FAO), Qu Dongyu, World Trade Organization (WTO) Director General Ngozi Okonjo-Iweala and World Food Program (WFP) Executive Director David Beasley issued the following joint statement calling for urgent action to address the global food and nutrition security crisis.

We wish to express our sincerest condolences to the people of Türkiye and the neighboring Syrian Arab Republic, who have suffered from the recent earthquakes. Our organizations are closely monitoring the situation, assessing the scale of the disaster and working to mobilize the necessary support in accordance with each other’s mandates and procedures.

Globally, poverty and food insecurity are increasing after decades of development progress. Disruptions in supply chains, climate change, the COVID-19 pandemic, financial tightening through rising interest rates, and the war in Ukraine have caused an unprecedented impact on the global food system, and the The most vulnerable are the most affected. Food inflation remains high around the world, with dozens of countries experiencing double-digit inflation. According to the WFP, 349 million people in 79 countries suffer from acute food insecurity. The prevalence of malnutrition is also increasing, after three years of deterioration. This situation is expected to worsen and in 2022 and 2023 global food supplies are projected to fall to the lowest level in three years[1]. The need is especially pressing in 24 countries that FAO and WFP have identified as hotspots, 16 of which are in Africa[2]. Fertilizer affordability, defined by the ratio of food prices to food prices[3], is also the lowest since the 2007/08 food crisis, which is leading to lower food production and affecting small farmers to a greater extent, worsening local food prices, which are already high. For example, the reduction in 2022 production of rice, of which Africa is the world’s largest importer, coupled with the prospect of lower stocks, are of great concern. In response to inflation in food, fuel and fertilizer prices, countries have spent more than US$710 billion on social protection measures covering 1 billion people, of which approximately US$380 billion is to subsidies[4]. Yet in low-income countries, just US$4.3 billion has been spent on social protection measures, compared to US$507.6 billion in high-income countries.

In order to prevent the food and nutrition security crisis from worsening, urgent new measures are required to i) address pockets of hunger, ii) facilitate trade, improve the functioning of markets and strengthen the role of the private sector, and iii) ) reform and redirect harmful subsidies with efficiency and careful targeting. As they respond to the crisis, countries need to find a balance between urgent short-term interventions and long-term resilience efforts.

1. Addressing pockets of hunger

We urge governments and donors to support country efforts to address needs in hot spots, share information, and strengthen crisis preparedness. WFP and FAO urgently need funds to immediately reach the most vulnerable people . In 2022, WFPand its partners reached an unprecedented number of people (more than 140 million) with food and nutrition assistance, based on record contributions of $14 billion, $7.3 billion of which came from the US government. WFP sent more than US$3 billion in cash transfers to people in 72 countries and supported school feeding programs in 80 countries, benefiting 15 million children through direct support and more than 90 million children through strengthening of the Government’s national school feeding programmes. fao _has invested USD 1 billion to support more than 40 million rural inhabitants with urgent agricultural interventions. These activities focused mainly on the 53 countries listed in the global report on food crises. The World Bankwill provide a US$30 billion food and nutrition security package to cover the 15 months from April 2022 to June 2023, including US$12 billion in new projects, which have been committed ahead of schedule. This also includes $3.5 billion in new financing for food and nutrition security in hot spots. In addition, the Bank has allocated $748 million from the $1 billion International Development Association Crisis Response Service (SRC) early response lending modality to primarily address needs in hotspots, and is mobilizing additional funds for the SRC. Resources should also be mobilized for the Poverty Reduction and Growth Trust Fund of theFMIto provide concessional financing to low-income countries with balance of payments needs. So far, the IMF’s new Food Shock Window has supported Ukraine, Malawi, Guinea, and Haiti, and the institution has provided financial support to nine countries facing acute food insecurity through new or expanded programs, emphasizing the strengthening of social protection networks and policies to help address the impact of the food crisis. The Global Alliance for Food Security supports improved crisis preparedness by developing and implementing multi-sectoral food security crisis preparedness plans in 26 countries, which must have the support of governments and donors. It also continues to monitor the severity of the food crisis and the financing of the global response through the Global Panel on Food and Nutrition Security. We also welcome the efforts of all parties to mobilize increased financing for Africa’s agricultural transformation, as outlined in the Dakar Declaration[5], and would like to thank David Beasley, WFP Executive Director, for the great job done during his tenure.

2. Facilitate trade, improve the functioning of markets and strengthen the role of the private sector

Countries must minimize trade distortions, strengthen the provision of public goods, and allow the private sector to contribute significantly to improving food security outcomes. We reiterate our urgent call to countries to i) avoid policies such as export restrictions, which can hinder access to food for poor consumers in low-income food-importing countries; ii) support trade facilitation measures to improve the availability of food and fertilizers, iii) support trade finance initiatives in a transparent and non-discriminatory manner, and iv) honor the commitments made at the 12th WTO Ministerial Conference [ 6] .While countries have lifted some export bans on wheat and rice, new export restrictions and bans, particularly on vegetables, are hindering availability on world markets. Global food security can be strengthened if governments support both food producers and consumers in smart and targeted ways, for example by strengthening the provision of public goods to sustainably improve agricultural productivity. Countries can use e-voucher systems for fertilizers and avoid large-scale public procurement and subsidized distribution schemes, whether for agricultural inputs or products, that scare away the private sector. The Platform for Global Food Security ofIFC , endowed with USD 6 billion, supports farmers to access fertilizer and other critical supplies, and helps private companies make longer-term investments, focusing on improving the resilience of agri-food systems and efficiency in the use of fertilizers. Countries must follow the FAO International Code of Conduct for the Use and Management of Fertilizers to manage nutrients sustainably for food security[7].

3. Reform and redirect harmful subsidies with efficiency and careful targeting

Countries should reform and redirect universal general subsidies into temporary and better targeted programs for global food security and sustainable food systems, taking into account the key aspects of: i) efficiency, ii) fiscal and cost sustainability, iii ) flexibility, iv) administrative complexity, v) equity, and vi) strengthening resilience and sustainability.Most of the global response to inflation in terms of social protection comes in the form of subsidies, half of which are untargeted, inefficient and costly for governments with already limited resources. Support should be expanded for countries to strengthen and implement comprehensive social protection strategies that are viable and adequately responsive to crises. Policies and reforms supported with financing from the IMF and the World Bank have focused on the transition from general measures to more specific approaches. Countries need to re-examine and reform their support for agriculture, which amounted to some US$639 billion annually between 2016 and 2018 and has been increasing ever since. Of every dollar spent, only 35 cents ends up with farmers[8]. Much of this support encourages inefficient use of resources, distorts world markets, or undermines environmental sustainability, public health, and agricultural productivity. Without ignoring the difficulties inherent in large-scale regulatory reforms[9], this funding needs to be modified and redirected in ways that strengthen the resilience and sustainability of the agrifood system, including through the adoption of good agricultural practices, research and innovation (referring, for example, to the efficiency of fertilizer application and alternatives to synthetic fertilizers), extension and advisory services, the improvement of infrastructure and logistics, and the use of digital technologies that increase productivity in a sustainable way.

Steps are already being taken to address underlying structural challenges in social protection and in food and fertilizer markets, but more concerted action is needed in these three key areas to avoid a protracted crisis. We are committed to working together and impact effectively to support the most vulnerable.

Source: World Food Programme

To expedite the end-to-end integration of influenza and SARS-CoV-2 surveillance, the WHO Ethiopia Country Office and the WHO Regional Office for Africa organized a two-week on-site laboratory training course for staff of the National Influenza Centre, Ethiopia Public Health Institute, Addis Ababa, Ethiopia.

The course provided hands-on training and an in-depth understanding of next-generation sequencing (NGS), data analysis, and sharing of genetic data to public-access databases. The training also significantly increased the SARS-CoV-2 sample throughput with improvement in data quality, bioinformatic analysis and the processing of information.

Held at the Ethiopia Public Health Institute (EPHI) in Addis Ababa from 5-16 December 2022, the training was part of WHO Global Influenza Programme (GIP) support to national influenza laboratories in the WHO African Region.

Over the past two years, the GIP has leveraged the capacities of Global Influenza Surveillance and Response System (GISRS) laboratories to incorporate SARS CoV-2 testing into influenza sentinel surveillance testing. SARS CoV-2 surveillance, as part of influenza surveillance, allows for the global respiratory disease surveillance system to monitor organisms with pandemic potential. In 2021, GIP selected influenza laboratories in nine countries in the WHO African Region (Algeria, Cameroon, Cote d’Ivoire Ghana, Ethiopia, Sierra Leone, Kenya, Madagascar, and Mauritania) to participate in a project to expedite integration of SARS-CoV-2 into influenza surveillance.

A key aspect of this initiative is to support National Influenza Centres (NICs) to develop robust genomic surveillance capacities through sequencing influenza and SARS-CoV-2 isolates and sharing the information (genetic sequence data and metadata), to public-domain (Genbank) or public-access databases (GISAID). GISAID is a repository for sequence data which also provides analysis tools for genetic sequence and related clinical, epidemiological, geographical, and species-specific data.

In this context an expert from WHO Collaborating Centre (WHO CC) for Reference and Research on Influenza, Victorian Infectious Disease Reference Laboratory, Melbourne, Australia provided next-generation sequencing training to scientists from the National Influenza Centre at the Ethiopian Public Health Institute, Addis Ababa. NIC scientists were mentored to complete runs of next-generation sequencing and they successfully, obtained 37 whole genome sequences from SARS-CoV-2 positive samples. As mentioned, the course significantly improved their sample throughput and the quality of data was also improved with 100% genome coverage with no gaps. Based on the results obtained during the course, NIC scientists provided clade/lineage information of the most recent SARS-CoV-2 outbreak to the Ethiopian government.

To further establish their capacity, NIC Ethiopia staff were also supported by WHO to attend the International Influenza and SARS-CoV-2 Genetic Sequencing Course that was held in January 2023 in Ghana. This was organized by the WHO Regional Office for Africa and GIP in partnership with the United States Centers for Disease Control and Prevention, the Association of Public Health Laboratories and the Ghana NIC. WHO and the WHO Collaborating Centre in Melbourne will continue to provide training and mentoring support to the Ethiopia NIC. WHO will continue to strengthen respiratory disease surveillance across the African Region as part of pandemic preparedness and response efforts.

Source: World Health Organization

The Joint Committee (JC) for implementing and monitoring the “Agreement for Lasting Peace in Ethiopia through a Permanent Cessation of Hostilities” held its inaugural meeting at the African Union Commission Headquarters in Addis Ababa, Ethiopia, today, 10th February 2023.

Chaired by Ambassador Bankole Adeoye, African Union (AU) Commissioner for Political Affairs, Peace and Security, the Joint Committee comprises representatives of the Parties and the Inter-Governmental Authority on Development (IGAD). The Committee took stock of progress made in implementing the Peace Agreement and considered the operations of the Monitoring Verification and Compliance Mechanism (MVCM) deployed to Mekelle, comprising the Team of African Experts and Liaison Officers of the Parties.

The Committee welcomed the positive dividends of the peace process between the Parties, most notably the restoration of essential services, including banking, telecommunications, medical and humanitarian support in Tigray, and called on the Parties to do more to facilitate unimpeded road access and land transport, and expedite the reopening of schools and other educational facilities in the Region.

The Joint Committee also commended the steadfast commitment and good faith implementation displayed by the two Parties so far, under the leadership of the Ethiopian Prime Minister and the TPLF, with the unalloyed support provided under AU auspices through the Chairperson of the AU Commission and the three-member High-Level Panel for the Ethiopian peace process. The Committee called upon all AU Partners to intensify their support for the disarmament, demobilization and reintegration (DDR) outlined in the Pretoria Agreement and the Nairobi Declarations I and ll.

The Committee agreed on the urgent need for the Parties to commence the political dialogue to address outstanding issues and for the AU to enhance the geographical coverage, capacities and resourcing of the MVCM. The JC reaffirmed the commitment to continue collaborating with the Parties to consolidate lasting peace in the Tigray region.

Source: African Union

Current Situation

Since the first disease outbreak news on the global cholera situation was published on 16 December 2022, the global situation has further deteriorated with additional countries reporting cases and outbreaks.

Since mid-2021, the world is facing an acute upsurge of the 7th cholera pandemic characterized by the number, size and concurrence of multiple outbreaks, the spread to areas free of cholera for decades and alarming high mortality rates.

In 2021, 23 countries reported cholera outbreaks, mainly in the WHO Regions of Africa and the Eastern Mediterranean. This trend continued into 2022 as 30 countries across five of the six WHO regions reported cholera cases or outbreaks. Among those, 14 had not reported cholera in 2021, including non-endemic countries (Lebanon and Syria) or countries that had not reported cases over three years (Haiti and the Dominican Republic), while most of the remaining countries reported higher case numbers and case fatality ratios (CFR) than in previous years.

As of 1 February 2023, at least 18 countries continue to report cholera cases (Table 1 A & B in the PDF). As according to the seasonality patterns large parts of the world are in currently in low or interepidemic transmission period this number could increase in the months to come.

The mortality associated to those outbreaks is of particular concern as many countries reported higher CFR than in previous years. The average cholera CFR reported globally in 2021 was 1.9% (2.9% in Africa), a significant increase above acceptable (<1%) and the highest recorded in over a decade. Preliminary data suggests similar trend for 2022 and 2023.

The potential drivers of the outbreaks and challenges impacting response activities were highlighted in the last Disease Outbreak News. The simultaneous progression of several cholera outbreaks, compounded in countries facing complex humanitarian crises with fragile health systems and aggravated by climate change, poses challenges to outbreak response and risks further spreading to other countries.

The overall capacity to respond to the multiple and simultaneous outbreaks continues to be strained due to the global lack of resources, including the oral cholera vaccine, as well as overstretched public health and medical personnel, who are dealing with multiple disease outbreaks at the same time.

Based on the current situation, including the increasing number of outbreaks and their geographic expansion, as well as a lack of vaccines and other resources, WHO assesses the risk at the global level as very high.

Epidemiology

Cholera is an acute diarrheal infection. When severe, it is characterized by extreme watery diarrhoea and potentially fatal dehydration. It is caused by the ingestion of food or water contaminated with the bacterium Vibrio cholerae. It has a short incubation period, ranging between twelve hours and five days. Most people will develop no or mild to moderate symptoms; about 20% of ill persons develop acute watery diarrhoea with severe dehydration and are at risk of death. 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.

Seven distinct pandemics of cholera have been recorded over the past two centuries. The seventh pandemic, which is still going on now, is considered to have started in 1961. During the first two decades, following (re)introduction, many countries transitioned to becoming cholera-endemic. While global incidence greatly decreased in the late 1990s, cholera remains prevalent in parts of Africa and Asia.

The global burden of cholera is largely unknown because the majority of cases are not reported, however, previous studies estimate 2.9 million cases, and 95 000 deaths occur annually.

Regional overview

In the table in the PDF, countries under monitoring are described. These include countries with active outbreaks of cholera and those which reported outbreaks in 2022. Other factors including the length of the outbreak, the size of vulnerable populations, and the overall contextual challenges are also taken into consideration.

WHO Region of Africa: The ongoing conflict in the province of North Kivu in the Democratic Republic of the Congo (DRC) led to an increased influx of internally displaced people (IDPs) to camps close to Goma, during the last months of 2022. The lack of access to water and sanitation in the camps fueled the ongoing cholera outbreak. Additionally, the rainy season is worsening the cholera situation in other eastern provinces, increasing the risk of regional spread. Burundi recently declared a cholera outbreak in the city of Bujumbura, along the shores of Lake Tanganyika and near the border with the province of South Kivu in DRC. While the number of reported cases in some countries with widespread outbreaks in 2022, such as Cameroon and Nigeria, is currently declining, the situation in Malawi continues to deteriorate in early 2023 as it reports over 600 new cases per day. The country is experiencing its deadliest cholera outbreak in history with a continually high CFR (>3%) since March 2022. In addition, neighbouring Mozambique has registered a sharp increase in cases and alerts since mid-December 2022, with cases reported from five provinces, including provinces bordering Malawi.

On 26 January 2023, Zambia notified WHO of a cholera outbreak in the Eastern province bordering Malawi and Mozambique. There remains a high risk of spread to other countries in the region, including Tanzania and Zimbabwe. Additionally, three countries in the Horn of Africa (Ethiopia, Kenya, and Somalia in the Eastern Mediterranean Region) are reporting ongoing cholera outbreaks. The continued drought is driving population movements which increase the risk of spread of cholera, and high levels of malnutrition, which increase the risk of severe outcomes of cholera in the region. There are multiple graded emergencies and stretched resource and human capacity due to other public health emergencies (COVID-19, mpox, malnutrition). Many affected areas are highly insecure and there is limited access to the population, which has limited access to healthcare. Climate change is leading to drought in some areas in Africa, and floods in others, resulting in increased population displacement and reduced access to clean water. High CFRs were reported from multiple outbreaks. There is high risk of regional spread in both Southern Africa with the rainy/cyclone season approaching and in the Lake Chad basin where there is limited response capacity due to insecurity.

WHO Region of the Americas: The situation in Haiti’s Ouest Department (which includes the metropolitan area of Port-au-Prince) is stabilizing. The department reported a third of the confirmed cases reported during the October-November 2022 peak. However, the outbreak is not yet under control and suspected and confirmed cases of cholera continue to be reported in all ten departments of the country. In addition, imported cases and limited local transmission are being reported from Santo Domingo, the capital of neighbouring Dominican Republic.

The mobility of the local population — although restricted because of the severe insecurity in the country and lack of fuel — represents a continued risk of national and international spread. Additional exportations from Haiti to other countries and territories in the Region of the Americas are possible. According to the 2 December 2022 AMRO rapid risk assessment the risk in Hispaniola is evaluated as Very High and the regional risk is assessed as Moderate. Efforts are ongoing to improve surveillance and laboratory capacity in the region. A cholera vaccination campaign is underway on Hispaniola Island.

WHO Eastern Mediterranean Region: Weak surveillance systems (e.g. sentinel, hospital-based surveillance) in many countries of the region make the interpretation of data challenging. The region is characterized by stretched staff capacity due to complex humanitarian crises, and emigration of trained staff. The outbreaks in the region are spreading, with population movement exacerbated by conflict, climate change, droughts, and flooding. In 2022, the first cholera outbreak in over 10 years was reported in Lebanon and Syria, while Pakistan recorded its largest outbreak in decades. Cases in Afghanistan, Lebanon, Pakistan and Somalia are currently declining, and other countries in the region which reported outbreaks in 2022, such as Iraq and IR Iran, remain under monitoring. The widespread outbreak continues in parts of Syrian Arab Republic, and risk of further spread to other countries in the region and beyond persist.

WHO European Region: Cholera is not endemic in the WHO European Region. Current robust public health systems, including access to adequate hygiene and sanitation standards at community and healthcare facilities coupled with surveillance and response capacities, lower the risk of further transmission following importation. However, countries bordering Syria and Lebanon, where large ongoing outbreaks are reported, may have a heightened risk of introduction and onward transmission in particular settings e.g., amongst refugee and displaced persons (Türkiye). A heightened risk of cholera outbreaks in Türkiye should be anticipated given the recent large earthquake that struck the southern and central parts of the country on 6 February 2023, and has had a devastating impact on infrastructure. In addition, in November 2022, Israel reported to WHO the detection of toxigenic Vibrio cholerae O1 in environmental samples from the Yarmuch stream upon its entry into Israel. Israel has taken substantive proactive measures to prevent cholera introduction and transmission and, as a result, the overall risk is considered low. The ongoing war in Ukraine stands to further worsen environmental and sanitary conditions and weaken health infrastructure in this area, however, cholera occurrence is of lower risk during winter months.

In November of 2022, WHO European Region IHR invited Member States to report any imported or autochthonous case of cholera on an ad hoc basis to support global outbreak monitoring. As of 27 December 2022, 28 cases of cholera have been reported to WHO by eight European Region Member States, of which 24 were linked with travel to cholera-affected countries.

WHO South-East Asia Region: The expected post-monsoon peak in 2022 was not apparent. Low-level transmission continues in Cox’s Bazaar in Bangladesh in 2023, particularly among Forcibly Displaced Myanmar Nationals (FDMN). Both India and Nepal, which reported outbreaks in 2022, remain under monitoring. There is limited surveillance (often sentinel-based) and low reporting. There is continued risk of export to other regions.

WHO Western Pacific Region: In the Philippines, recurrent cholera outbreaks were reported in 2022 with a cumulative number of recorded cases three times higher than in 2021. While countries of the region have overall good control capacity, there is inadequate monitoring of drinking water quality.

Public health response

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

Coordination

Cholera headquarter Incident Management System Team (IMST) has been established.

The multi-region cholera event was graded at the global level as a grade 3 emergency, the highest grade, on 26 January 2023.

Providing a forum for technical expertise exchange through the Global Task Force on Cholera Control (GTFCC) coordination, and cooperation on cholera-related activities to strengthen the country’s capacity to prevent and control cholera.

Providing technical support to all ongoing outbreaks (laboratory, case management, OCV, IPC, WASH).

Collaborating with key partners (UNICEF, MSF) to coordinate supply and optimal access to supplies.

Leveraging resources to support global monitoring of the cholera pandemic, provide technical support to countries, enhance data collection and reporting, strengthen advocacy, and provide medical and non-medical items to countries in need, especially for case management and diagnosis.

Supporting the deployment of experts through Global Outbreak Alert and Response Network (GOARN), and Standby Partners.

Risk communication and community engagement partners activated through the Collective Service.

Conducting advocacy and resource mobilization activities to support cholera prevention and control at national, regional, and global levels.

Surveillance

Strengthening surveillance including strengthening diagnostic algorithms, use of rapid diagnostic tests, collecting and transporting of samples, and strengthening laboratory capacity to culture V. cholerae.

Vaccination

Providing guidance to identify target populations for vaccination and requesting vaccine through the ICG mechanism, in the context of acutely limited supply.

Supporting advocacy to increase OCV production and engage new vaccine manufacturers.

Working with countries to identify the areas/hotspots where vaccination is most needed.

Case management

Strengthening access and improving care quality for patients by setting-up dedicated healthcare facilities (Cholera Treatment Centers (CTCs) and Cholera Treatment Units (CTUs)) which provide: 1) high quality triage; 2) focused and protocolized clinical management; 3) identification and management of complications. This requires a skilled workforce and clear clinical pathways, ensured through training for health workers and provision of technical guidance. Communities also need to be engaged to ensure rapid hydration support to people with suspected cholera and rapid care seeking behaviour.

Embedding Oral Rehydration Points (ORPs) into the response to provide early intervention, which reduces the risk of severe disease and improves the referral processes when hospitalization is required.

Harmonizing clinical data collection, reporting, and enabling quality improvement and audit through case report forms and common documentation

Infection Prevention and Control (IPC)

Supporting countries to assess and implement safety and quality of care focused interventions in health facilities to reduce risk of health care associated cholera infections

Risk communication and community engagement (RCCE)

Working closely with communities, Member States and partners to establish RCCE coordination mechanisms embedded within the broader outbreak response, mapping partners, identifying at risk communities and trusted channels/influencers, (especially WASH interventions, case management, vaccination campaigns and community based surveillance).

Providing support to maintain and build trust and manage risk perception and knowledge among communities about the disease, its symptoms, associated risks, precautions to take, and when to ensure adequate hydration and seek treatment when symptoms appear.

Collecting, analysing and using social and behavioural data should be to inform the outbreak response to understand behavioural drivers of transmission, effective interventions and knowledge, attitudes and practices over time.

Water, Sanitation, and Hygiene (WASH)

Working closely with communities, Member States and partners to strengthen water, hygiene, and sanitation systems through multi-sectoral mechanisms, including IPC and guidance on drinking-water quality surveillance.

Supporting countries for the implementation of effective cholera control strategies and monitoring of progress.

Supporting communities to advocate for, plan and implement sustainable WASH interventions to reduce the risk of cholera outbreaks and support response efforts.

Operations, Support, and Logistics (OSL)

Working closely with suppliers to secure Cholera Kits, sourcing other WASH supplies, and establishing a pipeline for bulk items.

WHO risk assessment

The risk of cholera is not equally distributed between regions, countries or within countries. The risk of cholera increases with decreasing access to clean water and sanitation.

However, there are a number of outbreaks occurring simultaneously across all six WHO regions (the African Region, the Region of the Americas, the Eastern Mediterranean Region, the European Region, the South-East Asia Region, the Western Pacific Region), which are straining the overall epidemic response capacity. Protracted cholera outbreaks are exhausting public health response personnel and depleting global and local resources.

Several countries including Cameroon, Ethiopia, Haiti, Lebanon, Nigeria (north-east of the country), Pakistan, Somalia, Syria and the Democratic Republic of Congo (eastern part of the country) are in the midst of complex humanitarian crises with fragile health systems, inadequate access to clean water and sanitation and have insufficient capacity to respond to the outbreaks. Climate change and a lack of development are also contributing to outbreaks.

In addition, many affected countries have highly mobile populations that may spread cholera to neighbouring countries (e.g. high risk of spread between Malawi and Mozambique, and to Tanzania, Zambia and Zimbabwe; the surge in cases in DRC’s North and South Kivu provinces increases the risk for spread to Burundi, Rwanda, Uganda; in Somalia, the uncontrolled cross-border movement of people, including refugees/asylum seekers with neighbouring countries especially Ethiopia, Kenya, Djibouti and Yemen; heavy population movement between Pakistan-Afghanistan, Iraq-Iran; the outbreak from Syria has spread to Lebanon with a continued risk of spread into Jordan). There is also a risk of spreading to currently unaffected areas by international travel to countries such as Sierra Leone and Liberia, which are at high risk for cholera outbreaks. After at least 10 reported imported cases from Haiti between October 2022 and January 2023, the neighbouring Dominican Republic continues to report cases linked to local transmission in 2023. There is the risk of further spread in the Americas. Cross-border population movements and increased global travel following the lefting of COVID-19-related restrictions, increase the risk of further international spread.

In October 2022, the ICG made the unprecedented decision to temporarily suspend the second dose of OCV for outbreak response, due to the global shortage of OCV, which continues in 2023. Although effective, the single-dose strategy will result in a shortened duration of vaccine-induced immunity, particularly in children under five years of age, leaving the populations vulnerable to cholera the following year.

Based on the current situation, in particular: 1) the increasing number of outbreaks and geographical expansion; 2) the complex humanitarian context of many crises; 3) continuous risk of spread; 4) lack of vaccines and limited response capacity (supplies, human resources), the risk at the global level is assessed as very high and cholera remains a global threat to public health and an indicator of inequity and lack of social development.

WHO advice

WHO recommends improving access to proper and timely case management of cholera cases, improving access to safe drinking water and sanitation infrastructure, as well as improving infection prevention and control in healthcare facilities. These measures along with the promotion of rapid hydration and care seeking behaviour for potential cholera cases and preventive hygiene practices and food safety in affected communities are the most effective means of controlling cholera. Listening to and understanding community concerns, needs, challenges and capacities and positioning communities as partners in the planning and implementation of response efforts is key. This includes understanding and addressing barriers that impact the uptake of protective behaviors, the impact of stigma and discrimination and trust in health systems, actors and authorities. Recognizing community knowledge and capacities and systematically involving communities in strengthening WASH, community-based surveillance, case management and safe and dignified burial practices will build trust and help align health system response efforts with community needs. Equipping health workers to work with communities to ensure rapid care seeking behaviour and to hold safe and dignified burials will be essential to maintain trust between communities and the health system.

The OCV should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in targeted areas known to be at high risk for cholera. Given the limited supply of OCV globally, RCCE and vaccine demand efforts should be a critical part of vaccination campaigns to ensure maximum uptake.

WHO recommends Member States to strengthen and maintain surveillance for cholera, especially at the community level, for the early detection of suspected cases and to provide adequate treatment and prevent its spread. Early and adequate treatment limits the CFR of patients to less than 1%.

WHO does not recommend any travel or trade restrictions on Member States based on the currently available information. However, as the outbreak also affects border areas where there is a significant cross-border movement, WHO encourages Member States to ensure cooperation and regular information sharing across all levels of the organization so that any spread across the border is quickly assessed and contained.

Source: World Health Organization