United Nations officials are expressing concern that a new cholera outbreak in conflict-ridden Sudan, declared 10 days ago, could widen dramatically in the wake of increased rainfall and flooding. Some 658 cases of cholera have been reported since 12 August, with 28 deaths, the World Health Organization (WHO) revealed in its latest situation report, published Friday. 

The last outbreak of cholera in May saw more than 11,300 cases and at least 300 deaths.

Twelve of Sudan’s 18 states are struggling to simultaneously contain outbreaks of three or more diseases. The worsening humanitarian situation, fueled by 16 months of fighting between the Sudanese Armed Forces and the insurgent Rapid Support Forces (RSF), crippling humanitarian aid deliveries, have left embattled health workers coping with outbreaks of measles, malaria, and dengue, along with the deadly diarroheal disease.  

Now, with heavy rains deluging the country, cholera cases have “surged,” said UN High Commissioner for Refugees (UNHCR) Representative in Sudan Kristine Hambrouck at a press briefing in Geneva on Friday.

“Risks are compounded by the continuing conflict and dire humanitarian conditions, including overcrowding in camps and gathering sites for refugees and Sudanese displaced by the war, as well as limited medical supplies and health workers. This is in addition to overstretched health, water and sanitation and hygiene infrastructure – all of which have been heavily impacted by the war,” she said.

Since the start of the devastating civil war in April 2023, the violence between the RSF (RSF) and the Sudanese Armed Forces have displaced over 10.2 million people internally – and forced another 2.1 million people into neighboring countries – creating the largest refugee crises in the world along with widespread hunger as well as widening pockets of outright famine in the western Darfour region. 

With large scale displacement, violence, and attacks on humanitarian aid, Sudan’s health system has quickly deteriorated. The WHO reports that over two-thirds of the country’s healthcare centers are not operational, and the ones still functioning are “at risk of closure due to shortages of medical staff, supplies, safe water, and electricity.” Furthermore, targeted attacks on hospitals, like June’s siege on the western Sudanese city of El Fashir, and its only maternity hospital, have left only 2% of the population with adequate healthcare.

“A new wave” of cholera roars through eastern provinces after heavy rains

Just a few months into the fighting, in June 2023, cholera broke out in a dozen Sudanese states. Since then, these states have reported more than 11,000 cases and 316 deaths. At the country level, cases peaked over the winter of 2023.  But the country’s eastern Red Sea state, at the epicenter of the outbreak, continued to see new cases. 

Just south of the capital state of Khartoum, the Sudan Federal Ministry of Health officially declared a new outbreak in Al Jazirah in the Kassala state earlier this month, raising concerns for outbreaks in an area where aid workers are repeatedly denied access. 

“Of particular concern is the spread of the disease in areas hosting refugees, mainly in Kassala, Gedaref and Jazirah states. In addition to hosting refugees from other countries, these states are also sheltering thousands of displaced Sudanese who have sought safety from ongoing hostilities,” said UNCHR in a statement.

In Kassala’s refugee camps, “people live on top of each other, they are hugely overcrowded,” said Hambrouck. “The water systems that were in place do not have the capacity to respond, it really needs massive investments.”

Yet the risk of cholera is not constrained to within Sudan’s borders. In the neighboring countries of Chad and South Sudan, UNCHR has reported an elevated risk of cholera outbreaks in refugee sites amid the onset of the rainy season. 

“We are also concerned for the health and protection of Sudanese refugees who fled the country,” said Hambrouk. “Our teams have reported an increase in malaria cases…amid alarming rates of malnutrition, and cases of measles, acute respiratory infections, acute watery diarrhea, and the risk of outbreaks of cholera.”

WHO scaling up cholera immunization campaign – but malaria and measles also threaten

Despite these challenges, an initial vaccination campaign  in Kassala state successfully protected more than 50,000 people from cholera, with hundreds of thousands more doses on the way. 

“The vaccination campaign already started and we used the 51,000 doses that were already in the country,” said Dr Shible Sahbani, WHO Representative in Sudan. Speaking from Port Sudan, he confirmed that the inoculation campaign concluded in Kassala state on Thursday. “We were aiming to reach the 97 per cent of the target population,” he said, adding that the UN health agency has also secured the approval to procure an additional 455,000 doses of cholera vaccine – “good news in the middle of this horrible crisis.”

Malaria continues to be a leading infectious cause of morbidity and mortality in Sudan. In the past decade, malaria cases increased by more than 40%, most likely due to frequent flooding, population movement, and the emergence of a new, and more invasive mosquito vector, anopheles stephensi. The WHO reports that between November 2023 and July 2024, over 1.67 million cases have been reported from 15 states. 

This comes just two years after the WHO congratulated Sudan on its steps in vector control – efforts that have now been derailed by the civil war. 

The WHO situation report also highlights a concerning numbers of measles cases – nearly 5,000 of a disease that is vaccine-preventable since late 2023. Low immunization rates and hard-to-access areas in places like Darfur and Kordofan states means that the risk of measles remains high, prompting the WHO and its partners to gear up for a large-scale campaign in the coming months.

Yet concerns over funding and humanitarian access may hamper the global health agency and its partners to implement a campaign at that scale. Of the $ 1.5 billion required by UNHCR and other partners for the Regional Refugee Response Plan (RRRP) to provide assistance in countries bordering Sudan, just 22% has been received. The inter-agency response inside Sudan is only 37% funded.

Even with funding, an “immediate ceasefire” and unimpeded and safe humanitarian access is needed to ensure aid can reach those who need it, said UNICEF spokesperson James Elder at the Geneva press briefing. Recent US-mediated peace talk efforts fell through after both warring parties failed to show up for talks last week in Geneva.

Image Credits: WHO, WHO, WHO, WHO.