African Cholera Outbreaks Driven by Years of Under-Investment in Water and Sanitation
Infectious Diseases 06/06/2025 •
People collect water from a pump in Kinshasa in the Democratic Republic of Congo. Cholera is an acute enteric infection, primarily linked to insufficient access to safe water and proper sanitation.

Cholera in Africa is being driven by years of under-investment in water and sanitation, according to the Africa Centres of Disease Control and Prevention (Africa CDC).

Four countries – Angola, Democratic Republic of Congo (DRC), Sudan and South Sudan  – account for over 85% of the continent’s cholera cases and all have above-average death rates, according to Dr Ngashi Ngongo, Africa CDC incident lead on mpox.

Access to clean water, sanitation and hygiene (WASH) is poor in all four countries. Only 35% of Sudanese have access to safe water, and although the DRC leads the group, only around two-thirds of its citizens have clean water, according to the Africa CDC.

Only 16% of those living in South Sudan have access to basic sanitation and almost three-quarters of the rural population practises open defecation.Only 10% of schools in South Sudan have handwashing facilities for children.

Half the Angolan population has basic sanitation, the best of the group.

South Sudan has the biggest cholera outbreak with 48,828 cases and 908 deaths. It is followed by DRC with 25,520 cases and 557 deaths, then Angola with 21,000 cases and 630 deaths and Sudan with 13,743 cases and 296 deaths, Ngongo told the Africa CDC media briefing on Thursday.

Ngongo said that the expected case fatality rate should be around 1% but this was far higher in all four countries. South Sudan’s rate is 1.9%, DRC is 2.1%, Sudan is 2.5%, and Angola is 3%.

Multi-sectoral, continental commitment

Earlier in the week, African Heads of State from the 20 countries worst affected by cholera convened and resolved to create a continental Incident Management Support Team (IMST) similar to that coordinating the mpox response, to reinforce cross-border surveillance. 

The countries also pledged to establish national presidential task torces on cholera to “strengthen multisectoral coordination, mobilise domestic resources, and enforce accountability frameworks”, according a media release from Africa CDC. 

Angolan President and African Union chairperson João Manuel Gonçalves Lourenço urged countries to “invest robustly in water, sanitation, and health systems”. 

Meanwhile, Africa CDC Director General Dr Jean Kaseya told the leaders that the systemic drivers of the crisis were “limited WASH infrastructure, insecurity, weak coordination, and vaccine shortages”.

“Africa needs 54 million doses of oral cholera vaccine annually but receives barely half. This gap is unacceptable. Urgent action is needed to scale up local production and secure supply,” said Kaseya.

Only one manufacturer is currently making the vaccine globally, producing around half the vaccines that are needed. 

“Africa needed 80 million doses but only received 26 million doses [in 2024] because doses had to be distributed also to other regions,” said Ngongo.

“This is the reason why there’s a greater push from Africa CDC, and now also from the Head of State for local manufacturing,” he said, adding that $150 million was needed to finance this.

In closing, Zambian President and meeting host Hakainde Hichilema said: “We have issued a clear Call to Action. Now we must deliver—through scaled-up domestic investments, strengthened cross-border coordination, and community-driven responses. Africa needs one continental IMST, one community-centred plan, and one accountability framework.”

Mpox ‘most concerning’ in Sierra Leone

The mpox outbreak in Sierra Leone, which accounts for over half of the new mpox cases in the past week, is the “most concerning”, said Ngongo.

The country has 4,032 suspected cases reported so far (3140 confirmed) and 15 deaths. Cases seem to be falling, with 531 cases in the past week in comparison to 684 the previous week, but the country’s surveillance is inadequate, he noted.

“What is of really great concern is the test positivity rate, which is at 93% overall for the entire country, with seven districts reporting 100% positivity rate,” said Ngingo.

“This means that people come themselves to health facilities, and those that come are already at advanced stage. It’s a reflection that the surveillance is primarily passive.” 

However, Ngongo acknowledged that Sierra Leone’s surveillance programme involving community health workers “has stopped because of difficulties in funding”.

While mpox appears to be stabilising in the DRC, which is where the majority of cases are, the country’s low testing rate “makes it very difficult to interpret the stabilisation that we are seeing”, said Ngongo.

However, he confirmed that conflict in North and South Kivu provinces was settling, enabling vaccination.

The DRC is the only country that is now vaccinating children below 18 years using the Japanese vaccine LC16. Japan has donated 4.5 million LC16 doses to the DRC, while France has donated 100,000 Bavarian Nordic doses and the United Arab Emirates has donated 20,000 doses.

Image Credits: Eduardo Soteras Jalil/ WHO.

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