Slipping Away? A Review of Humanitarian Capabilities in Cholera Response

A Humanitarian Outcomes report raises concerns about the global capacity for cholera response аnd control, and asks whether past progress has been lost

Over the past two years, there has been a notable uptick in cholera outbreaks and deaths.

The greater number of countries experiencing cases, combined with an unusual geographical distribution of outbreaks and unacceptably high case fatality rates, has raised concerns about the global capacity for cholera response аnd control, and whether past progress has been lost.

Although cholera outbreaks can have multiple contributing factors – including armed conflict, development and governance failures, and the effects of climate change – these are largely outside the influence of humanitarian actors.

While not discounting broader issues, such as lack of investment in water and sanitation infrastructure, and other more sustainable solutions, the report focuses on humanitarian response, including capacities, competencies and coordination.

Summary of the report

Current situation: not an ‘unprecedented’ surge, but a warning sign for response capacities

Global data shows an increase in outbreaks and cases compared with recent years, but the data is not perfect and needs improvement.

The increase in case fatality rates over the past four years is more concerning, with some places reporting rates four times higher than the acceptable threshold of 1%.

Experts agree that no one should die from the disease – the rise in fatality rates raises questions about the quality of the response.

In fragile contexts hosting humanitarian responses, high case fatality rates indicate serious gaps in capacity for rapid action and effective treatment.

Global strategic coordination: good on paper, lagging in implementation

The Global Task Force on Cholera Control and other global entities have made progress in bringing together national and international actors to tackle cholera.

International aid and public health communities, as well as national governments, have endorsed the global strategy for cholera control, but only two countries (Ethiopia and Kenya) have implemented national plans – the Roadmap 2030 strategy for eradicating cholera is unlikely to be met.

Lack of funding to implement national cholera plans and expert surge capacity for outbreak coordination and response is a major challenge.

The visibility of cholera has been low amid other competing emergencies, including other disease outbreaks and following the Covid-19 pandemic.

Technical operational coordination is hindered by inadequate technical capacity at the World Health Organization (WHO) and its partners, as well as barriers to effective coordination with its counterpart, the United Nations Children’s Fund (UNICEF), and partners in water, sanitation and hygiene (WASH).

Structural impediments and conflicting priorities

Containing cholera outbreaks means identifying and treating cases quickly, and eliminating sources of contamination.

Cholera control and response rely on integrating health and WASH activities, and educating people about the disease to prevent transmission.

There are coordination challenges between humanitarian sectors, relief and development actors, and different ministries in national governments.

Public health initiatives on cholera focus on short-term interventions to control outbreaks, while global WASH efforts work towards elimination in the longer term – adequate WASH systems have benefits that go beyond cholera and acute diarrhoeal diseases.

But the funding modalities of major donors reinforce divides and perpetuate the reactivity trap.

Operations at country level: capacity gaps and loss of ‘the basics’

Aside from their own declining technical capacities in WASH, humanitarian agencies miss opportunities for investing in more durable WASH solutions due to short-term funding modalities and cost calculations.

Basic interventions such as oral rehydration therapy and in-home treatment in the health sector have also declined, possibly due to public health systems de-emphasising cholera and patients’ preferences for over-medicalised interventions.

The case-area targeted intervention approach for cholera is effective, but more data is needed, and clearer standard operating procedures tailored to different contexts have to be developed.

Health officials in vulnerable countries lack rapid, ground-level technical support from epidemiologists and cholera response specialists, especially when responses are hindered by insecurity and access constraints.

A primary supplier's decision to cease production in 2023 has caused a critical shortage of oral cholera vaccine (OCV), further weakening capacities for prevention and response.

Data challenges

There is a lack of reliable data on cholera globally and operationally – misaligned incentives cause over- and under-reporting of cholera cases.

Surveillance and reporting quality vary widely by country, with delays in sharing data between agencies – timely data is essential to prevent the spread of cholera.

The Ebola response has shown that good reporting and surveillance are possible – the current state of data on cholera globally is unacceptable.

• Areas for action
• Get back to basics – cholera patients usually do not require extensive medical intervention; responders should focus on providing ORS at community level. Training should be provided to responders on a continual basis, and risk communication should emphasise the use of simple treatment at or close to home.
• Strengthen coordination for effective response – WHO and UNICEF should clarify and strengthen their joint coordination role in cholera response, with dedicated coordination staff deployed in outbreak countries to ensure effective programme integration.
• Build regional-level capacity – donors and state members of regional organisations could develop cholera-specific surge capacities at regional level to address overstretch and human resource limits in global agencies.
• Improve data – improving data gathering and sharing is essential for effective cholera surveillance and response, but responders should not delay action in responding to suspected outbreaks while waiting for perfect data.
• Make funding more flexible and risk responsive – donors should increase access to rapid funding for emergency interventions, including flexible financing with ‘crisis modifiers’ and greater amounts allocated through humanitarian pooled funding mechanisms.
• Increase vaccine availability –– greater production of OCV is urgently needed; advocacy is needed to work with pharmaceutical companies to increase availability.
• Stay focused – cholera deserves special attention and vigilance due to its unique features and the need for preparedness and rapid response; public health entities should maintain a distinct capacity focused on cholera.

Project summary

This report was the third in a series of rapid reviews conducted by HO under the Humanitarian Rapid Research Initiative, commissioned and supported by the UK Humanitarian Innovation Hub (UKHIH) with UK aid from the Foreign, Commonwealth & Development Office.

It was part of a programme of rapid analytical reviews HO is leading to inform and steer humanitarian responses in new or newly exacerbated crises.

The analyses produced focus on one or two critical issue areas where research efforts have the potential to make the greatest policy or operational impact.

Methodology

For each review, a team led by HO and including various international experts and institutional partners conducted key informant interviews.

The team reviewed relevant literature and data, implementing surveys of people affected by crises and/or aid providers.

HO data assets and tools provided quantitative data on operational presence and coverage (GDHO), perspectives of people affected perspectives (CORE), and operational security (AWSD).

The UK Humanitarian Innovation Hub is an independent entity hosted within Elrha and fully funded by the UK Foreign, Commonwealth & Development Office.