Cholera is endangering children globally
Learn why outbreaks are occurring and how UNICEF is responding.
Cholera doesn't know borders. Despite being preventable and easily treatable, children continue to suffer from the potentially fatal disease. After years of steady decline, cholera has made a devastating comeback. More than 1.1 billion people are at risk, with children under 5 especially vulnerable. The intestinal infection often spreads because of a lack of clean water and sanitation facilities. Children living in volatile and unstable communities are particularly at risk. Thankfully, vaccines and treatments are available. UNICEF is working to make sure that these provisions reach the children that need them the most. The goal is to make sure that by 2030 cholera is no longer a threat to public health. Here's what you need to know about cholera and the efforts to eliminate the disease.
What is cholera?
Cholera is an intestinal infection. It’s caused by ingestion of food or water that’s contaminated with the bacterium Vibrio cholerae. Researchers conservatively estimate that every year, there are as many as 4 million cholera cases globally and as many as 143,000 deaths. Young children, especially those under the age of 5, bear the brunt of the disease. Furthermore, malnourished children are more vulnerable to experiencing severe symptoms. Cholera is a preventable and easily treatable disease.
What makes a country cholera-endemic?
A cholera-endemic area is where cases have been detected during the past 3 years, and there’s evidence that it was caused by local transmission, rather than being imported from elsewhere. Meanwhile, a cholera outbreak (epidemic) can occur in countries where cholera does not regularly occur or in endemic countries.
How does cholera spread?
Cholera disproportionately affects the world’s poorest and most vulnerable communities. A lack of access to clean water and sanitation facilities is closely linked to an increased likelihood of cholera transmission. That means that children who are living in urban slums and camps for internally displaced people or refugees are particularly vulnerable. That’s because the minimum requirements of clean water and sanitation are sometimes not met. Poor water management, increased poverty and conflicts make safe water more and more scarce. Between 2010 and 2021, almost all cholera cases – 97 per cent – were seen in countries with the lowest levels of water and sanitation services.
Climate change also contributes to the spread of cholera. Significant rainfall and flooding, which is becoming more frequent, results in an intensified water cycle. That in turn affects access to clean water in communities already vulnerable to these events. Consequently, families and their children often rely on unsafe water, which exposes them to greater risk of contracting the water-borne disease.
If a child is infected with cholera, what are the symptoms?
Most children infected with cholera will have no or mild symptoms, and through the use of oral rehydration solution, they can be successfully treated. But if left untreated, the disease can kill within hours. Severe cases of cholera require rapid treatment with intravenous fluids and antibiotics.
After ingesting contaminated food or water, it can take between 12 hours to 5 days before a child begins to show symptoms. The bacteria remain in the faeces for up to 10 days after infection and is shared back into the ecosystem, which could lead to other people potentially being infected. Cholera can cause acute watery diarrhoea with severe dehydration, which can prove to be fatal. When experiencing diarrhoea, infants and children are at greater risk of dehydration compared to adults, and more so if they are malnourished.
How is cholera treated?
If infected with cholera, most children can be treated successfully through the quick administration of oral rehydration solution (ORS), which is a mixture of salt and sugar. UNICEF and the World Health Organization distribute sachets of this solution that need to be dissolved in clean water.
From 2000 to 2019, the total annual number of deaths from diarrhoea among children under 5 decreased by 61 per cent. This decline can be linked to the expanded use of ORS for diarrhoea treatment.
If a child is severely dehydrated, treatment beyond oral rehydration solution is necessary. In this instance, intravenous fluids should be rapidly administered, and the child may also require antibiotics to reduce the duration of diarrhoea.
During a cholera outbreak, it is crucial that these treatments are readily accessible. That requires distributing oral rehydration solution to treatment clinics in communities that are significantly impacted. If treated early and properly, the fatality rate can be reduced dramatically.
For children under the age of 5, zinc is an important adjunctive therapy. Zinc is a vital micronutrient that becomes drained during diarrhoea. When given as a supplement, it reduces the duration and severity of the illness, and can also reduce the risk of recurrences in the short term.
What can be done to prevent the spread of cholera?
A multifaceted approach is key to controlling cholera and reducing deaths. First and foremost, ensuring that every child has access to safe drinking water and adequate sanitation is essential. It’s also important that children in communities at risk have access to the WHO pre-qualified oral cholera vaccines.
Furthermore, community engagement plays an important role. Effective and engaging programmes can help to promote protective hygiene measures such as handwashing with soap and the safe disposal of faeces.
Additionally, given that cholera is an easily treatable disease, quick access to treatments during an outbreak, including oral rehydration solution, zinc and antibiotics is crucial. With early and proper treatment, the fatality rate should remain below one per cent.
Effective surveillance systems are also necessary to monitor and control the spread of cholera. The surveillance data gathered should be translated into accessible information that can be used effectively at a local, national and global level.
Are there vaccines available to prevent cholera?
There are currently three World Health Organization pre-qualified oral cholera vaccines: Dukoral, Shanchol and Euvichol-Plus. In order to be fully protected, all of these vaccines require two doses. The International Coordinating Group (ICG), which UNICEF is a member of, manages the global stockpile of oral cholera vaccines. The group has conducted mass vaccination campaigns resulting in more than 100 million doses of oral cholera vaccines being administered. These campaigns have focused on areas experiencing an outbreak, particularly in highly endemic areas known as “hotspots” and in areas at increased vulnerability during humanitarian crises.
Where in the world are we seeing cholera outbreaks?
In recent years, we’ve seen a surge in the number of cholera outbreaks globally. 30 countries faced cholera outbreaks in 2022 – an alarming 145 per cent average increase from the previous five-year average. Countries like Lebanon and Syria reported cholera for the first time in decades.
Meanwhile, an outbreak in Haiti in 2022 had a significant impact on children. There have been thousands of suspected cases, resulting in hundreds of deaths in that country. UNICEF has warned that about 40 per cent of the cases in Haiti are among children. The country is dealing with the aftermath of natural disasters, political instability, continued clashes between armed groups and a deepening nutrition crisis.
Furthermore, in early 2023, Malawi reported that it was experiencing its deadliest cholera outbreak in recorded history. With limited resources and overburdened health systems, health workers in the country are stretched to their limits. The outbreak has impacted all 29 districts in Malawi with thousands of children contracting cholera. In East and Southern Africa, outbreaks continue to spread across borders with multiple countries experiencing a cholera epidemic.
In addition to the spread of cholera in Africa and the crisis in Haiti, we’ve also witnessed recent cholera outbreaks in the Middle East. Thousands of cases have been detected, which has resulted in dozens of preventable deaths. Other neighboring countries are at significant risk.
UNICEF is working tirelessly to respond to these outbreaks in these impacted countries and regions.
How is UNICEF responding to these cholera outbeaks?
UNICEF has stepped up efforts to respond to cholera outbreaks in coordination with national authorities and partners. That includes widely distributing millions of water treatment tablets to ensure families in impacted communities have access to safe water.
We also supply local health departments with oral rehydration salt sachets and zinc, in addition to providing acute watery diarrhoea kits to treat moderate and severe cases. Additionally, UNICEF is increasing access to ready-to-use therapeutic food, as malnutrition is a leading cause of death from cholera.
We’re also helping frontline workers in communities experiencing outbreaks. UNICEF trains these workers in cholera awareness, including transmission, symptoms, treatment and prevention mechanisms. Furthermore, we’re airing prevention spots on local radio and TV stations to raise awareness about the situation.
Furthermore, UNICEF is working to pilot and identify climate-informed and environment-informed approaches that can support in mitigating outbreaks and minimizing their spread when they occur.
These are just a few of the extensive steps and provisions UNICEF adopts to respond to the threat of cholera.
Are we close to eliminating cholera?
Through the successful adoption of prevention measures and increased access to cholera treatment methods, including oral rehydration salt and zinc, we’re closer than ever to ensuring that no child dies from this preventable disease.
In 2021, UNICEF distributed over 93 million zinc tablets and more than 30 million oral rehydration salt sachets worldwide.
But these outbreaks that we continue to witness prove that cholera still presents an immediate and potentially grave danger to families, particularly in unstable and volatile communities worldwide.
Worryingly, as outbreaks become more regular and demand for supplies increases, we’re seeing a shortage in essential cholera commodities, including oral rehydration salts and rapid diagnostic kits. At the same time, the global stockpile of oral cholera vaccines is significantly depleted.
To overcome this global emergency, in the immediate term we must reach affected populations to prevent and control cholera through humanitarian action. In the longer term, we need to invest in strengthening water and sanitation systems to prevent future outbreaks.
Despite the challenges that exist, in coordination with our partners, UNICEF has a global strategy that provides a concrete path toward a world in which cholera is no longer a threat to public health, by 2030. As the recent cholera outbreaks demonstrate, a recommitment to realize this goal is more urgent than ever.
The strategy focuses on close to 50 countries that have been affected by cholera in recent years. You can learn more about this plan here.