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Patient being transported to the Cholera Treatment Center in the Paraíso neighborhood, Luanda ...
More Province, Angola, January 2025 Cholera is making a comeback. A new outbreak in Angola , West Africa started on January 7, 2025, and is likely to get worse as it spreads to more rural regions. Thus far this year, there have been approximately 13,255 cases and 488 deaths, according to Dr.
Indrajit Hazarika, a physician and public-health practitioner who is the World Health Organization’s Country Representative for Angola. In aggregate, he notes that the death rate has been approximately 3.7%, which far exceeds WHO’s goal of less than 1%.
Angola is one country among many dealing with cholera. In 2024, there were almost 810,000 cases and 5,900 deaths worldwide reported to the WHO, which are approximately 50% higher than in 2023. Through March 30 this year, 25 countries have reported 116,574 cases and 1,514 deaths, with African countries recording the highest numbers.
According to the WHO, “Conflict, mass displacement, disasters from natural hazards, and climate change have intensified outbreaks, particularly in rural and flood-affected areas, where poor infrastructure and limited healthcare access delay treatment.” Cholera is a scourge of antiquity believed to have impacted human populations dating back thousands of years, killing millions and impacting human history. Caused by the bacteria Vibrio cholerae and leading to rapidly fatal diarrhea, cholera is notable for causing explosive epidemics and pandemics.
We are in the midst of the seventh historical pandemic of cholera, which began in 1961, with populations in the poorest regions of the world the hardest hit. Cholera is spread by the fecal-oral route, meaning that an individual who is infected passes the bacteria into the environment in their feces. Populations without access to clean water and sanitation may consume contaminated water or food and are therefore susceptible to outbreaks.
I asked Dr. Hazarika what factors facilitated the outbreak of cholera in Angola, which he said comes down to “the limited access to clean water and sanitation for the population at large.” He added that only two-thirds of the population in Angola has access to clean water and three-quarters have access to adequate sanitation.
The individuals with clean water access drop “substantially” in the rural areas, making the population vulnerable to cholera and other diarrheal disease outbreaks. Cholera causes acute, high-volume, watery diarrhea (up to 10-20 liters a day) and vomiting; therefore, victims have difficulty keeping up with the fluid loss and can die in a matter of hours without appropriate treatment. As diarrhea progresses, it may become clear with white mucus, giving it the classic appearance of “rice water” with a fishy odor.
As victims become dehydrated, they may become lethargic, develop sunken-appearing eyes and their skin becomes lax and “tents.” The pulse becomes weak and ironically, as victims become severely dehydrated, the stool volume may decrease as they go into shock. Cholera can be diagnosed by using a rapid test kit on stool or culturing stool in the lab.
Once the outbreak was determined by testing, though, Dr. Hazarika said that WHO uses a more efficient clinical definition for suspected and confirmed cases to determine who is likely infected. “In an outbreak of this scale and magnitude,” he said, “any case that presents as a case of acute watery diarrhea is being treated as a case of cholera.
” Unlike many other infectious diseases, antibiotics play a minor role in treating cholera, although they can reduce the volume of diarrhea and decrease spread. I asked Dr. Hazarika what measures are taken to treat the victims in Angola.
He responded that providing adequate fluids is the mainstay of therapy, and “it has been dependent on the severity of the cases.” In the most severe cases, patients are given intravenous fluids with supplemental antibiotics. Those with mild to moderate disease can be given oral rehydration solutions.
Children are given supplemental zinc tablets. WHO technician providing guidance to volunteers at the Cholera Treatment Centre in Paraiso, Luanda ..
. More Province, Angola, February 2025 Dr. Hazarika said that the WHO’s goal is to save lives as it provides support to the government and the Ministry of Health through coordinating a multisectoral and multiprong response, providing disease surveillance, data systems and rapid response.
Partners have included UNICEF, the Africa CDC and the US CDC, which participate as part of the national incident management teams and response. UNICEF has been particularly instrumental shoring up “WASH,” which focuses on water quality testing, sanitation, hygiene and mapping points of access to safe water sources. The WHO also helps with daily situation reports, case management, setting up cholera treatment centers, risk communication, training healthcare workers and rapid response teams and direct community engagement on preventive measures, as well as providing access to oral rehydration.
Dr. Hazarika doesn’t do this work from an ivory tower. He and his team members provide support on the ground and are working tirelessly in the community searching for cases.
Epidemiologists call such work “shoe leather epidemiology,” which means that the workers on the ground are wearing the soles of their shoes thin from all the walking it requires. In fact, the symbol of an epidemiologist is a shoe with a hole in the sole. A logo showing the worn shoe symbolizing "shoe leather" epidemiology.
The fundamental way to prevent cholera is to provide access to safe drinking water and proper sanitation. Vaccines have also been used in outbreak responses, but the supplies are limited, and many countries don’t have access to them. The WHO has facilitated use of vaccines in Angola’s outbreak response, though.
According to Hazarika, 925,000 individuals were vaccinated initially in February and March in the first three provinces where the outbreak started. As the disease has spread to 17 of the 21 provinces, another 700,000 doses were procured in March and are being administered based on surveillance data “in hot spot areas in the effort to contain the spread of the outbreak,” Hazarika said. I asked Dr.
Hazarika whether he had noted any change with the pullback of US support for international health. He responded that “The absence is palpable in this response.” In the past, both the CDC and WHO benefited from technical cooperation.
It has been more difficult to garner support, cooperation has been affected, and a more challenging fiscal environment with the decrease in US funding has impacted not only the WHO, but other agencies previously funded by the US that would play a role in response. The other concern we discussed was the global health security aspect. “What’s happening in Angola is probably what we’re seeing in several parts of the continent, especially in terms of cholera outbreaks,” Hazarika said, and heightens the risk for similar outbreaks elsewhere.
It is always preferable to contain an outbreak at the source. The outbreak in Angola illustrates this challenge as a “Wake up call” for the government, which highlighted major infrastructure gaps in water and sanitation and the need for investments in these aspects for the country. It started in the capital city of Luanda but has since spread to 17 provinces.
There is also risk of cross-border spread to other countries, such as the neighboring Democratic Republic of the Congo. “An outbreak somewhere can be an outbreak anywhere unless there are measures that are being taken to contain it,” said Hazarika, “so there is an imminent threat of the outbreak spreading.” As we concluded the interview, Dr.
Hazarika mentioned that he was heading out on a 5:00 am flight the next day to a province with the highest number of reported cases. He is thus following the time-honored tradition of an international health responder heading towards a “fire,” rather than away from it. As he noted, “The situation is that you probably don’t have enough fire extinguishers with you, but you still have to run into the fire.
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