Cholera cases could double over the next two decades if action is not taken now

21 March 2023
Medical staff and Dr Guilherme Tomo treating a cholera patient at the Mechanhelas District health centre. Niassa, Mozambique, March 2023.
Image: WaterAid/ Edson Artur at Signus

Download photosThe World Health Organization issued a stark warning that the current cholera crisis is a pandemic putting over one billion people at risk.

A perfect storm of climate change, conflict and financial crises along with human displacement have created an unprecedented global cholera crisis – sparking large-scale outbreaks in countries previously free of the highly contagious disease for many years.

The alarming surge in cases comes as the Global Task Force for Cholera Control (GTFCC) warns the worst could be yet to come. GTFCC modelling shows that population growth and rapid, unplanned urbanisation could lead to a doubling of cholera cases over the next 20 years if action is not taken imminently.

Cyclone Freddy is currently causing catastrophic flooding in both Malawi and Mozambique – countries that have serious cholera outbreaks - creating an acute risk of exacerbating spread of the disease.

Climate change increases the outbreak-risk of waterborne diseases, including cholera, by altering the temperature, rainfall levels, and frequency of extreme weather, and threatens to reverse progress made in recent years. The latest global surge of cholera cases has put one billion people in 43 countries at risk, the World Health Organization (WHO) has warned.

The alert comes as two vital meetings in the fight against the killer disease take place in New York - the Global Task Force for Cholera Control (GTFCC) annual meeting on Water Sanitation and Hygiene (WASH), and the first United Nations Water Conference since 1977 due to be attended by ministers from around the world this week from 22-24 March 2023.

Dr Nurullah Awal, Health Adviser for WaterAid Bangladesh chairs the WASH working group of the task force and urges world leaders to urgently invest in the clean water and sanitation services needed to stop cholera outbreaks for good.

Working closely with Dr Nurullah, Arielle Nylander, WaterAid’s Senior Health Policy Analyst, explained:

“Climate change is greatly increasing the vulnerability of many countries to cholera, including in fragile settings areas where the disease is not endemic. This is on top of longstanding drivers like conflict, poverty, humanitarian crises and population displacement. Economic challenges such as stretched public funding due to post-Covid recovery and the spill-over

effects of the war in Ukraine all combine to create a ‘poly-crisis’ with the ideal conditions for cholera proliferation.

“Water and sanitation services as well as hygiene behaviours represent the only long-term solution for ending cholera. Whilst oral vaccines can buy time, we cannot vaccinate our way out of this pandemic.

“They key is - and always has been - the provision of clean water, decent toilets and good hygiene. Cholera is an entirely WASH-preventable disease. World leaders, governments and donors must prioritise and put sustainable, predictable investment into climate-resilient WASH services for the whole population, especially the poorest and most vulnerable groups.”

The World Health Organization (WHO)’s cholera lead Dr Philippe Barboza, said:

“Prevention is key. Nearly half of the world lacks access to safely managed sanitation. Access to safe drinking water and sanitation are internationally recognised human rights. Making these rights a reality will also end cholera.”

Currently experiencing its worst-ever outbreak of cholera, according to WHO, is Malawi, where heavy rains are expected to further intensify the conditions in which the disease thrives. With the severity and frequency of storms worsening with climate change, the urgency of investing in climate-resilient water and sanitation services and infrastructure is paramount.

This need is currently demonstrated by the impact of Cyclone Freddy which has torn through Mozambique and Malawi over the last month. In its path, it has brought increased flooding and damage to water and sanitation infrastructure heightening the risk of current outbreaks spreading further.

As of 19 March 2023, Malawi’s total confirmed cases were at 54,839 with 1,684 total deaths – a fatality rate of 3.07%. In Mozambique, 11,158 cases have been registered with a total of 77 deaths. In Malawi three quarters of people do not have a decent toilet and around 30% do not have even a basic supply of clean water close to home, in Mozambique the figures are 63% and one third respectively.

But some areas have escaped those higher numbers, partly due to recent investment in improving water, sanitation and hygiene facilities.

Francis Nthonga, Medical Technician for Kawinga Health Care Facility in Machinga District, Malawi, said:

“We received aid from WaterAid for the construction of toilets and a water supply which has been very crucial in the containment of this [cholera outbreak] because patients were able to wash, where previously they used to go to the river. There would have been chaos if that was the same case today.”

Recent outbreaks are crossing borders into neighbouring Zambia and further afield in the Horn of Africa, across Ethiopia, Somalia and Kenya. Latest reports reveal there are currently 22 countries worldwide with outbreaks, as cholera’s upsurge continues where water and sanitation infrastructure is fragile.

Charifo dos Santos, 19, has just recovered from cholera in one of the worst hit areas of Mozambique, Mecanhelas in Niassa province.

"When I got the disease it was raining a lot and there was water flooding in the backyard which caused the toilet to overflow and I think that's what caused the cholera."

Guilherme Tomo, the Chief Medical Officer of Mecanhelas District, Mozambique said:

"Climate change is having a drastic effect on our health. When it rains more, there are problems of diseases because water for consumption mixes with dirty water, spreading cholera and other water-borne diseases. Also, when there is a lack of rain, the cholera cases start to skyrocket. Both excess rain and lack of rain impact the outbreak of cholera."

The medical team in Dr Tomo’s district is taking preventative measures to protect more than 340,000 inhabitants in the area from cholera. They are conducting daily lectures in hospitals and schools and broadcast campaigns on local community radio stations about the importance of home hygiene.

In March 2022, the Bangladesh capital Dhaka experienced its worst cholera outbreak for 60 years. Now, as the city welcomes the start of the holy month of Ramadan, Dr Nurullah highlighted the need to be on high alert. He placed critical importance on practising good hand hygiene, including during food preparation, and drinking safe, clean water as people come together to break their fast. This is especially pertinent for children who are at the greatest risk of severe outcomes from cholera.

Dr Nurullah Awal remained optimistic the city has learned many lessons from the previous outbreak and is pro-actively working to safeguard its citizens ahead of the summer season, when cholera cases usually peak. The city’s water authority says it is working to upgrade 80% of the water pipes by 2025 after widespread outbreaks took hold in and around Dhaka, with Dakshinkhan and Jatrabari amongst the worst affected areas.

Dr Nurullah Awal, Health Adviser for WaterAid Bangladesh, said:

“With the Health Directorate, we mapped the potential hotspots so that we will have fresh surveillance data coming from health centres as part of the country preparedness plan to rapidly support hospital and field staff. We’re aiming to ensure better community awareness of the importance of a safe water supply and sanitation. All these issues formed part of that discussion about Dhaka’s preparedness, if there is an outbreak this summer.”

New York, where the UN Water Conference will take place, was itself once wracked by cholera in the nineteenth century, when one percent of residents died of the disease during two outbreaks in the poorest, most crowded area of downtown Manhattan.

WaterAid is calling for governments to urgently accelerate universal access to water and toilets. High-level political will is desperately needed to prioritise and fund increased investment in clean water, decent sanitation and hygiene to tackle the underlying causes of cholera. Crucially, this would positively impact public health, economies, gender equality and entire societies in the face of climate change.

WaterAid's new policy paper ‘Ending the water, sanitation and hygiene crisis together’ calls on governments to provide the vision, drive and facilitate coordination to deliver progress on water, sanitation and hygiene (WASH) services in line with SDG 6 – universal WASH access. The paper also calls on development partners to improve coordination to avoid the fragmentation of investment and support in a bid to make water, decent toilets and hygiene a reality for everyone, everywhere.


Download photosFor more information, please contact:

In New York: Jeff Greene, Communications and Engagement Officer WaterAid America [email protected]; Aneesha Hampton Head of Communications, WaterAid Canada [email protected]

In London: Lisa Martin, Senior Media Officer WaterAid UK [email protected]; Safeeyah Kazi, Senior Media Officer WaterAid UK [email protected]; or call our after-hours press line on +44 (0)7887 521 552

Notes to Editors: WaterAid has published a new report in advance of the UN Water Conference available here.

The project referenced by Francis Nthonga in Malawi was funded by the Scottish Government’s International Development fund and Scottish Water fundraising.

WaterAid is working to make clean water, decent toilets and good hygiene normal for everyone, everywhere within a generation. The international not-for-profit organisation works in 28 countries to change the lives of the poorest and most marginalised people. Since 1981, WaterAid has reached 28 million people with clean water and nearly 29 million people with decent toilets.

For more information, visit our website, follow us on Twitter @WaterAidPress, @WaterAidUK, @WaterAid, or find us on Facebook, LinkedIn or Instagram.

  • 771 million people in the world – one in ten – do not have clean water close to home.
  • Almost 1.7 billion people in the world – more than one in five – do not have a decent toilet of their own.
  • Over 300,000 children under five die every year from diarrhoeal diseases caused by poor water and sanitation. That's more than 800 children a day, or one child every two minutes.
  • Investing in safely managed water, sanitation and hygiene services provides up to 21 times more value than it costs. 

[1] WHO/UNICEF (2021) Progress on household drinking water, sanitation and hygiene 2000-2020. Joint Monitoring Programme. Geneva: World Health Organisation. 

[2] WHO/UNICEF (2021) Progress on household drinking water, sanitation and hygiene 2000-2020. Joint Monitoring Programme. Geneva: World Health Organisation.

[3] WaterAid calculations based on: Prüss-Ustün A, et al. (2019). Burden of Disease from Inadequate Water, Sanitation and Hygiene for Selected Adverse Health Outcomes: An Updated Analysis with a Focus on Low- and Middle-Income Countries. International Journal of Hygiene and Environmental Health. vol 222, no 5, pp 765-777. AND The Institute for Health Metrics and Evaluation (2020) Global Burden of Disease Study 2019. Seattle, WA: University of Washington.

[4] WaterAid. (2021) Mission-critical: Invest in water, sanitation and hygiene for a healthy and green economic recovery.