Cholera Outbreaks in Africa

During the current seventh cholera pandemic, Africa bore the major brunt of global disease burden. More than 40 years after its resurgence in Africa in 1970, cholera remains a grave public health problem, characterized by large disease burden, frequent outbreaks, persistent endemicity, and high CFRs, particularly in the region of the central African Great Lakes which might act as reservoirs for cholera. There, cases occur year round with a rise in incidence during the rainy season. Elsewhere in sub-Saharan Africa, cholera occurs mostly in outbreaks of varying size with a constant threat of widespread epidemics. Between 1970 and 2011, African countries reported 3,221,050 suspected cholera cases to the World Health Organization, representing 46 % of all cases reported globally. Excluding the Haitian epidemic, sub-Saharan Africa accounted for 86 % of reported cases and 99 % of deaths worldwide in 2011. The number of cholera cases is possibly much higher than what is reported to the WHO due to the variation in modalities, completeness, and case definition of national cholera data. One source on country specific incidence rates for Africa, adjusting for underreporting, estimates 1,341,080 cases and 160,930 deaths (52.6 % of 2,548,227 estimated cases and 79.6 % of 209,216 estimated deaths worldwide). Another estimates 1,411,453 cases and 53,632 deaths per year, respectively (50 % of 2,836,669 estimated cases and 58.6 % of 91,490 estimated deaths worldwide). Within Africa, half of all cases between 1970 and 2011 were notified from only seven countries: Angola, Democratic Republic of the Congo, Mozambique, Nigeria, Somalia, Tanzania, and South Africa. In contrast to a global trend of decreasing case fatality ratios (CFRs), CFRs have remained stable in Africa at approximately 2 %. Early propagation of cholera outbreaks depends largely on the extent of individual bacterial shedding, host and organism characteristics, the likelihood of people coming into contact with an infectious dose of Vibrio cholerae and on the virulence of the implicated strain. Cholera transmission can then be amplified by several factors including contamination of human water- or food sources; climate and extreme weather events; political and economic crises; high population density combined with poor quality informal housing and poor hygiene practices; spread beyond a local community through human travel and animals, e.g., water birds. At an individual level, cholera risk may increase with decreasing immunity and hypochlorhydria, such as that induced by Helicobacter pylori infection, which is endemic in much of Africa, and may increase individual susceptibility and cholera incidence. Since contaminated water is the main vehicle for the spread of cholera, the obvious long-term solution to eradicate the disease is the provision of safe water to all African populations. This requires considerable human and financial resources and time. In the short and medium term, vaccination may help to prevent and control the spread of cholera outbreaks. Regardless of the intervention, further understanding of cholera biology and epidemiology is essential to identify populations and areas at increased risk and thus ensure the most efficient use of scarce resources for the prevention and control of cholera.